Definitive childlessness in women with multiple sclerosis: a multicenter study

[Pregnancy and breastfeeding in women with multiple sclerosis]

The diagnosis of multiple sclerosis (MS) in women of reproductive age is associated with many uncertainties regarding childbearing and lactation. Pregnancies of MS patients are not usually considered high-risk pregnancies per se. The likelihood of pregnancy complications or adverse pregnancy outcomes is not increased by the disease; however, a careful planning of pregnancy is important in order to choose the treatment option with the greatest benefit for the mother and the least possible risk for the baby. For highly active courses of the disease, anti-CD20 antibodies, cladribine, or continued administration of natalizumab show the best data. Patients with MS can be supported in their desire to breastfeed. If women have had a very active disease course, it is recommended that treatment should be started as soon as possible postpartum. Interferon-beta preparations, glatiramer acetate and ofatumumab are also approved for use during breastfeeding but off-label breastfeeding is also possible with other monoclonal antibodies.

Practical Considerations for Managing Pregnancy in Patients With Multiple Sclerosis: Dispelling the Myths

Purpose of Review

Lack of consistent data and guidance have led to variations between clinicians in the management of pregnancy in women with multiple sclerosis (MS). Pregnant and/or lactating women are often excluded from clinical trials conducted in MS, and thus, the labeling for most disease-modifying therapies (DMTs) excludes use during pregnancy. This has led to heterogeneity in interpretation and labeling regarding the safety of DMTs during pregnancy and lactation and the required preconception washout periods. This review identifies key themes where there is conflicting information surrounding family planning and pregnancy in MS, focusing on the most common discussion points between physicians and patients during preconception planning, pregnancy, postpartum, and lactation. The goal was to inform the patient-physician conversation and provide best practice recommendations based on expert clinical expertise and experience.

Recent Findings

We outline the latest evidence-based data for DMT use during pregnancy and lactation, the effect of MS on fertility and fertility treatments, the risk of adverse pregnancy and delivery outcomes, the risk of postpartum relapse, and immunization and clinical imaging safety during pregnancy and breastfeeding.

Summary

Management of family planning and pregnancy in patients with MS requires the most current information. Health care providers should discuss family planning early and frequently with patients with MS, and partners where practicable. Because management of pregnant people with MS will often require a risk/benefit analysis of their needs, shared decision-making in family planning discussions is emphasized. Additional data are needed for specific and underrepresented populations with MS (e.g., single parents or those from the LGBTQ+ community) and those at risk of racial and socioeconomic disparities in care. Pregnancy registries and the design and conduct of clinical trials focused on pregnant and lactating patients should provide additional data to guide the ongoing management of patients with MS.

Evidence from Finland and Sweden on the relationship between early-life diseases and lifetime childlessness in men and women

The percentage of people without children over their lifetime is approximately 25% in men and 20% in women. Individual diseases have been linked to childlessness, mostly in women, yet we lack a comprehensive picture of the effect of early-life diseases on lifetime childlessness. We examined all individuals born in 1956-1968 (men) and 1956-1973 (women) in Finland (n = 1,035,928) and Sweden (n = 1,509,092) to the completion of their reproductive lifespan in 2018. Leveraging nationwide registers, we associated sociodemographic and reproductive information with 414 diseases across 16 categories, using a population and matched-pair case-control design of siblings discordant for childlessness (71,524 full sisters and 77,622 full brothers). The strongest associations were mental-behavioural disorders (particularly among men), congenital anomalies and endocrine-nutritional-metabolic disorders (strongest among women). We identified new associations for inflammatory and autoimmune diseases. Associations were dependent on age at onset and mediated by singlehood and education. This evidence can be used to understand how disease contributes to involuntary childlessness.

Impact of endocrine dysregulation on disability and non-motor symptoms in pediatric onset multiple sclerosis

Background

Pediatric onset multiple sclerosis (POMS) commonly occurs at the time of various endocrine changes. Evaluation of the impact of endocrine status on disease severity in POMS has not been previously explored.

Objective

This study sought to evaluate if sex and stress hormones in children with POMS impact motor and non-motor diseases severity.

Methods

A single-center case control study was performed. Individuals with POMS were compared to individuals without neurologic disease. Each individual had three blood draws assessing stress and sex hormones between 07:00 and 09:00. Measures of fatigue (Epworth sleepiness scale), depression (PHQ-9), and quality of life (PedsQL) assessed at each visit.

Results

Forty individuals with POMS and 40 controls were enrolled. Individuals with POMS had lower free testosterone (p = 0.003), cortisol (p < 0.001), and ACTH (p < 0.001) and had higher progesterone (p = 0.025) levels than controls. Relapses and EDSS were not impacted by endocrine variables. The POMS cohort had a significantly higher Epworth score (p < 0.001), PHQ-9 score (p < 0.001), and lower PQL score (p < 0.001) than controls. Non-motor measures were not associated with endocrine status.

Conclusion

Free testosterone, cortisol, ACTH, and progesterone were abnormal in children with POMS although there was no association between endocrine status and markers of disease severity or non-motor symptoms of MS.

Optimizing the "Time to pregnancy" in women with multiple sclerosis: the OPTIMUS Delphi survey

Background

The debate on how to manage women affected by multiple sclerosis (MS) during reproductive age is still open, as is the issue of fertility in such patients. Main issue regard the identification of the optimal window for pregnancy and how to deal with medical therapy before and during conception. The aim of this Delphi consensus was to collect the opinions of a multidisciplinary group, involving reproductive medicine specialists and neurologists with experience in the management of multiple sclerosis women with reproductive desire.

Methods

Four experts plus scientific coordinators developed a questionnaire distributed online to 10 neurologists and later discussed the responses and amended a list of statements. The statements were then distributed via an online survey to 23 neurologists (comprising the first 10), who voted on their level of agreement/disagreement with each statement. Consensus was achieved if agreement or disagreement with a statement exceeded 66%.

Results

Twenty-one statements reached consensus after two rounds of voting, leading to the following main recommendations: (1) Fertility evaluation should be suggested to wMS, in case of the need to shorten time to pregnancy and before treatment switch in women on DMTs contraindicated in pregnancy, particularly in case of highly active disease and age > 35 years. (2) ART should not be discouraged in wMS, but the use of DMTs until pregnancy confirmation should be suggested; ART may be considered in order to reduce time to pregnancy in MS women with a reduced ovarian reserve and/or age > 35 years, but in case of an expected poor ART prognosis and the need for more than one ART cycle, a switch to a high-efficacy DMD before ART should be offered. (3) Oocyte cryopreservation may be considered in women with reduced ovarian reserve, with unpredictable time to complete diagnostic workup and achieve disease control; a risk/cost-benefit analysis must be performed in women >35 years, considering the diminished ovarian reserve.

Conclusion

This consensus will help MS neurologists to support family planning in wMS, respecting MS therapeutic needs while also taking into account the safety and impact of advancing age on fertility.

Knowledge and worries on motherhood choice in multiple sclerosis - a cross-sectional study on patient-reported outcome measures

BACKGROUND

Since multiple sclerosis (MS) is often diagnosed in young women, pregnancy is a common topic for women with MS (wwMS). The study aimed to assess the measurement properties of two patient-reported outcome measures on motherhood choice in MS, and to explore the information and support needs of wwMS concerning motherhood.

METHODS

We conducted an anonymous web-based survey to validate the motherhood/pregnancy choice and worries questionnaire (MPWQ, 31 items plus up to 3 additional items) and the motherhood choice knowledge questionnaire (MCKQ, 16 items). We used mailing lists and social media for nationwide recruitment in Germany, and included women of childbearing age with relapsing-remitting MS, clinically isolated syndrome or suspected MS who were considering pregnancy or were pregnant. For the MPWQ, we assessed item difficulty, discriminatory power, and internal consistency (Cronbach's alpha; CA). We analysed construct validity using the Leipzig Questionnaire of Motives to have a Child, the Decisional Conflict Scale, the Hospital Anxiety and Depression Scale, and the Pregnancy-Related Anxiety Questionnaire-revised 2. We studied the structural validity using exploratory factor analysis (EFA). The MCKQ was evaluated descriptively. We explored the information and support needs of wwMS on motherhood descriptively. We examined correlations between MCKQ, MPWQ and clinical characteristics and performed exploratory group comparisons considering the following binary variables: having children and being pregnant.

RESULTS

325 wwMS started the survey; 232 wwMS met our inclusion criteria and were analysed. Their mean age was 30 years (SD 5). Most women had relapsing-remitting MS (n = 218; 94%), 186 (80%) had no children, and 38 (16%) were pregnant. Internal consistency was good for the worries subscale (CA>0.8), while it was unsatisfactory for the attitude and coping subscales (CA<0.7). The EFA did not support the three-scale structure (coping, attitude, and worries). Due to these findings, we decided to keep the worries scale without any subscale. The items from the coping scale and attitude scale could be assessed as additional descriptive items. Convergent and divergent construct validity of the MPWQ was satisfactory. 206 wwMS (89%) completed the MCKQ. On average, 9 of 16 (56%) items were answered correctly (range 2-15), and the questionnaire showed a good balance between easy and difficult items. Questions on immunotherapy, disease activity, and breastfeeding were the most challenging. WwMS were confident in getting pregnant and raising a child (n = 222; 96%). Most wwMS were worried about postpartum relapses (n = 200; 86%) and the long-term effects of pregnancy on disease evolution (n = 149; 64%). About half of the wwMS (n = 124; 54%) did not know where to find professional help and 127 (55%) had no strategies to cope with future impairments so that they could take care of a child.

CONCLUSION

Our results support the suitability and acceptability of both questionnaires as potential patient-reported measures for assessment of knowledge and worries around motherhood/pregnancy in MS. The survey results highlight the need for evidence-based information on motherhood in MS to increase knowledge, reduce worries and support wwMS in making informed decisions.

Family planning considerations in people with multiple sclerosis

Multiple sclerosis is often diagnosed in patients who are planning on having children. Although multiple sclerosis does not negatively influence most pregnancy outcomes, less is known regarding the effects of fetal exposure to novel disease-modifying therapies (DMTs). The withdrawal of some DMTs during pregnancy can modify the natural history of multiple sclerosis, resulting in a substantial risk of pregnancy-related relapse and disability. Drug labels are typically restrictive and favour fetal safety over maternal safety. Emerging data reporting outcomes in neonates exposed to DMTs in utero and through breastfeeding will allow for more careful and individualised treatment decisions. This emerging research is particularly important to guide decision making in women with high disease activity or who are treated with DMTs associated with risk of discontinuation rebound. As increasing data are generated in this field, periodic updates will be required to provide the most up to date guidance on how best to achieve multiple sclerosis stability during pregnancy and post partum, balanced with fetal and newborn safety.

The role of sex and pregnancy in multiple sclerosis: what do we know and what should we do?

INTRODUCTION

Multiple sclerosis (MS) is more prevalent in women than in men. The sex of the patient, and pregnancy, are reported to be associated with the clinical features of MS. The mechanism of this is unclear.

AREAS COVERED

This review summarizes data about sex differences in MS and the role of pregnancy. Possible mechanisms for the effects of sex and pregnancy are summarized, and practical suggestions for addressing these issues are provided.

EXPERT OPINION

There is considerable interdependence of the variables that are associated with MS. Men have a worse outcome of MS, and this could be due to the same factors that lead to greater incidence of neurodegenerative disease in men. The possible role of parity on the long-term outcome of MS is of interest. Future studies that look at the mechanisms of the effects of the sex of the patient on the outcome of MS are required. However, there are some actions that can be taken without further research. We can concentrate on public health measures that address the modifiable risk factors for MS and ensure that disease is controlled in women who intend to become pregnant and use appropriate disease modifying agents during pregnancy.

Updated Perspectives on the Challenges of Managing Multiple Sclerosis During Pregnancy

Multiple sclerosis (MS) is a chronic immune-mediated, inflammatory, and degenerative disease that is up to three times more frequent in young women. MS does not alter fertility and has no impact on fetal development, the course of pregnancy, or childbirth. The Pregnancy in Multiple Sclerosis Study in 1998 showed that pregnancy, mostly in untreated women, did not adversely affect MS, as disease activity decreased during pregnancy (although it significantly increased in the first trimester postpartum). These findings, together with the limited information available on the potential risks of fetal exposure to disease modifying treatments (DMTs), meant that women were advised to delay the onset of DMTs, stop them prior to conception, or, in case of unplanned pregnancy, discontinue them when pregnancy was confirmed. Now, many women with MS receive DMTs before pregnancy and, despite being considered a period of MS stability, up to 30% of patients could relapse in the first trimester postpartum. Factors associated with an increased risk of relapse and disability during pregnancy and postpartum include relapses before and during pregnancy, a greater disability at the time of conception, the occurrence of relapses after DMT cessation before conception, and the use of high-efficacy DMTs before conception, especially natalizumab or fingolimod. Strategies to prevent postpartum activity are needed in some patients, but consensus is lacking regarding the therapeutic strategies for women with MS of a fertile age. This, along with the increasing number of DMTs, means that the decision-making processes in aspects related to family planning and therapeutic strategies before, during, and after pregnancy are increasingly more complex. The purpose of this review is to provide an update on pregnancy-related issues in women with MS, including recommendations for counseling, general management, use of DMTs in pre-pregnancy, pregnancy, and postpartum periods, and breastfeeding-related aspects of DMTs.

A Scoping Review of Breastfeeding in Women with Chronic Diseases

Background: Approximately 10-20% of mothers have a chronic disease. Studies on breastfeeding in women with chronic disease span multiple disciplines, and these have not been collated to synthesize knowledge and identify gaps. The objective of this review was to summarize published literature on breastfeeding in women with chronic disease. Methods: We conducted a scoping review of original research and systematic reviews identified in Medline, EMBASE, and CINAHL (1990-2019) and by hand searching on women with chronic diseases reporting on at least one breastfeeding-related topic. Conference abstracts, case-studies, and studies on pregnancy-induced conditions or lactation pharmacology were excluded. Content analysis and narrative synthesis were used to analyze findings. Results: We identified 128 articles that were predominantly quantitative (80.5%), conducted in Europe or North America (65.6%), analyzed sample sizes of <200 (57.0%), and published from 2010 onward (68.8%). Diabetes (42.2%), multiple sclerosis (MS; 19.5%), and epilepsy (13.3%) were the most common diseases studied. Breastfeeding was a primary focus in approximately half (53.1%) of the articles, though definitions were infrequently reported (32.8%). The most-studied topics were breastfeeding duration/exclusivity (55.7%), reasons for feeding behavior (19.1%), and knowledge and attitudes about breastfeeding (18.3%). Less studied topics (<10% of articles each) included milk expression behaviors, breastfeeding difficulties, and feeding supports. Conclusions: Existing literature focuses primarily on diabetes or MS, and breastfeeding behaviors and outcomes. Further research examining a broader range of chronic diseases, with large sample sizes, and sufficient breastfeeding measurement detail can improve our understanding of breastfeeding disparities in this population.

Pregnancy in patients with multiple sclerosis

Multiple sclerosis (MS) is an autoimmune disorder that affects ~2.5 million people globally. Women of reproductive age are highly susceptible to this disease. This study aims to explore the association between MS and pregnancy. Articles related to the topic under investigation were identified; the search terms included "pregnancy", "multiple sclerosis", "MS", and "women". Only articles published between 2010 and 2020 were included in the review. This review shows that researchers have attempted to explore the link between pregnancy and MS, and the results from previous studies indicate that pregnancy reduces the risk of MS relapse. However, evidence suggesting that pregnancy can affect the long-term progression of MS is lacking. The research results also indicate that MS does not increase the risk of maternal and fetal complications. MS remains a serious autoimmune disorder that affects many women worldwide. The data gathered during this review indicate that a significant correlation exists between pregnancy and MS relapse rates. The findings presented in this review can aid in the management of MS during pregnancy. Furthermore, these research results provide vital insights that caregivers can use to monitor patients with MS during pregnancy.

Multiple Sclerosis in Pregnancy and its Role in Female Fertility: A Systematic Review

Multiple sclerosis (MS) is a neurological disease that typically affects young women of reproductive age. There are still many questions and heterogeneous clinical approaches partly due to the lack of consensus and guidelines. For many years, women with MS have been discouraged from getting pregnant for fears that the disease might negatively affect the fetus or increase their obstetric risk or for claims that the disease might decrease fertility. However, fertility does not seem to be impaired to a larger extent in women with MS. Therefore, all healthcare providers involved in the follow-up of multiple sclerosis patients must be prepared to discuss future fertility, pregnancy, and others matters, in addition to providing them with the best possible counseling. This study presents data based on updated evidence and discusses fertility and pregnancy in patients with MS with respect to the impacts of pregnancy on the risk and prognostic factors tied to MS, and the impact of MS on pregnancy outcomes and fertility treatments administered to females with MS. In conclusion, a clear relationship between infertility and MS has not been established. There seems to exist a link between disease aggressiveness and progression with several processes that might impair fertility. However, MS does not stand as a contraindication to assisted reproductive technology. From the several studies analyzed, it is possible to conclude that pregnancy is possible in women with MS. It is important to discuss and plan the ideal moment to start treatment and managing pregnancy and contraception aiming at better results.

Influence of Pregnancy in Multiple Sclerosis and Impact of Disease-Modifying Therapies

Purpose of this Review: This article is a systematic review on the influence pregnancy has on multiple sclerosis and the resulting impact of disease-modifying therapies.

Findings: Multiple sclerosis predominantly affects young women with a clinical onset most often during the child-bearing age. The impact of multiple sclerosis and disease-modifying therapies on fertility, pregnancy, fetal outcome, and breastfeeding is a pivotal topic when it comes to clinical practice. The introduction of disease-modifying therapies has changed not only the natural history of the disease but also the perspective of pregnancy in women with multiple sclerosis. Family planning requires careful consideration, especially because many disease-modifying drugs are contraindicated during pregnancy. In this article, we review current evidence collected from published literature and drug-specific pregnancy registers on the use of disease-modifying therapies. Additionally, we discuss safety profiles for each drug and correlate them to both risk for the exposed fetus and risk for the mothers interrupting treatments when seeking pregnancy.

The relationship between disability and parental status: a register study of the 1968 to 1970 birth cohorts

BACKGROUND

Having children is a major life course event yet some disabilities could make it biologically challenging and some others could limit access to necessary socioeconomic resources. To date, there is relatively little data on disability and parental status and our study aimed to investigate this relationship.

METHODS

This longitudinal cohort study was based on register data obtained from all people born in Sweden from 1968 to 1970 (n = 440220). We performed descriptive analyses, graphical plots, logistic regression, and Cox regression analyses.

RESULTS

Our findings from both logistic regression and Cox regression indicated that individuals that started to receive disability benefits at an early age had reduced chances of having children during the follow-up duration. Men with disabilities were less likely to have children when compared to women with disabilities and to men and women without disabilities.

CONCLUSIONS

We found evidence that disability during early adulthood was associated with reduced chances of having children. Findings support policies and programmes aimed at promoting optimal health during early adulthood, as this would promote continued labour force participation, reduce early use of disability benefits, and possibly improve chances of becoming a parent.

The role of sex hormones in women with multiple sclerosis: From puberty to assisted reproductive techniques

BACKGROUND

Multiple Sclerosis is a multifactorial chronic autoimmune disease, affecting predominantly females in the fertile age. Sex hormones changes during a woman's life, from puberty to menopause, including pregnancy and puerperium, may influence the onset and course of Multiple Sclerosis. The effect of estrogen levels on immune, clinical and radiological aspects of Multiple Sclerosis, also stimulated investigation on the effect of sexual hormones therapies, such as oral contraceptives and assisted reproductive technique, on the Multiple Sclerosis course.

SEARCH STRATEGY AND SELECTION CRITERIA

A literature search for original articles and reviews was conducted in the databases, including PubMed, Scopus, and ClinicalTrials.gov of the U.S. National Library of Medicine site from 1988 to 2020.

RESULTS AND CONCLUSION

This review reports the effects of the physiological and iatrogenic hormonal changes either on immune or clinical or paraclinical features in the different life stages of women affected by Multiple Sclerosis.

Live birth rates, infertility diagnosis, and infertility treatment in women with and without multiple sclerosis: Data from an administrative claims database

BACKGROUND

Real-world data regarding live birth rates (LBRs) and infertility in women with multiple sclerosis (MS) are lacking. This study compared LBRs, infertility diagnoses, and infertility treatments in women with and without MS.

METHODS

Using a retrospective US administrative claims database, patients 18-55 years with MS were matched 1:1 to patients without MS to compare LBRs, infertility diagnoses, and infertility treatments used between cohorts.

RESULTS

Overall LBRs were lower in women with MS (n=96,937) versus women without (n=96,937; 5.0% vs 7.0%; p<0.0001). A greater proportion of women with MS than without had a diagnosis of infertility (8.5% vs 8.1%; p=0.0006). Fewer women with MS than without used any infertility treatment (1.0% vs 1.2%; p=0.0002). Among women with or without MS who received infertility treatments, no significant difference was observed in LBRs with oral (32.2% vs 31.5%; p=0.8536) or injectable (44.0% vs 49.3%; p=0.2603) treatment.

CONCLUSION

Women with MS had a lower LBR, received more infertility diagnoses, and were less likely to receive infertility treatment than women without MS. There was no difference in LBRs following infertility treatment. Claims-data studies provide valuable exploratory analyses that reflect interactions between patients and the healthcare system.

Knowledge and Attitudes Towards Pregnancy in Females with Inflammatory Bowel Disease: An International, Multi-centre Study

BACKGROUND AND AIMS

Poor knowledge of inflammatory bowel disease [IBD] in pregnancy underlies unwarranted voluntary childlessness [VC], and risks poorer obstetric outcomes and adverse fetal outcomes. IBD is increasing worldwide but education on IBD issues might be heterogeneous based on cultural differences and variations in models of care.

METHODS

Consecutive female IBD subjects aged 18-45 years were prospectively recruited from two dedicated IBD-pregnancy clinics, two multidisciplinary IBD clinics and nine general gastroenterology clinics. Subjects completed the validated CCPKnow [score 0-17] with questions on demographics, medical history and pregnancy knowledge. The primary outcome was knowledge per clinic-type and per geographical region.

RESULTS

Surveys were completed by 717 subjects from 13 hospitals across ten countries. Dedicated IBD-pregnancy clinics had the highest knowledge, followed by multidisciplinary IBD clinics then general IBD clinics (median CCPKnow 10.0 [IQR: 8.0-11.0], 8.0 [IQR: 5.0-10.5] and 4.0 [IQR:2.0-6.0]; p < 0.001). Median CCPKnow scores in Western, Asian and Middle Eastern clinics were 9.0, 5.0 and 3.0 respectively [p < 0.001]. Dedicated IBD-pregnancy clinics, IBD support organization membership, childbearing after IBD diagnosis and employment independently predicted greater knowledge. Patient perception of disease severity [r = -0.18, p < 0.01] and consideration of VC [r = -0.89, p = 0.031] negatively correlated with CCPKnow score. The overall VC rate was 15.0% [95% CI: 12.2-18.2]. VC subjects had significantly lower pregnancy-specific IBD knowledge than non-VC subjects (median CCPKnow 4.0 [IQR: 2.0-6.0] and 6.0 [IQR: 3.0-9.0] respectively; p < 0.001). Pregnancy-specific IBD knowledge and dedicated IBD-pregnancy clinic attendance were significant negative predictors of VC.

CONCLUSIONS

In this large international study we identified predictors of pregnancy-specific IBD knowledge. Dedicated IBD-pregnancy clinics had the greatest IBD-related pregnancy knowledge and lowest VC rates, reflecting the benefits of pre-conception counselling.

Reproductive intentions in childless female adolescent and young adult cancer survivors

OBJECTIVE

To examine the association between prior cancer treatments, medical comorbidities, and voluntary childlessness in reproductive-age women who are survivors of cancers diagnosed as adolescents and young adults (AYA survivors).

DESIGN

Cross-sectional analysis.

SETTING

Participants were recruited from California and Texas cancer registries, fertility preservation programs, and cancer advocacy groups.

PATIENT(S)

Women (n = 413) ages 18-40 who were diagnosed with cancer between ages 15 and 35, completed primary cancer treatments, had at least one ovary, and were nulliparous.

INTERVENTION(S)

Cancer treatment gonadotoxicity and medical comorbidities.

MAIN OUTCOME MEASURE(S)

Voluntary childlessness.

RESULT(S)

The mean age of survivors was 31.8 years (SD, 4.9) with a mean of 6.5 years (SD, 4.4) since cancer diagnosis. Breast (26%), thyroid (19%), and Hodgkin lymphoma (18%) were the most common cancers. Twenty-two percent of the cohort was voluntarily childless. Medical comorbidities, cancer diagnosis, prior surgery, prior chemotherapy, and prior gonadotoxic treatments were not significantly associated with voluntary childlessness. In adjusted analysis, survivors of older reproductive age (adjusted odds ratio = 2.97 [1.71-5.18]) and nonheterosexual participants (adjusted odds ratio = 4.71 [2.15-10.32]) were more likely to report voluntary childlessness.

CONCLUSION(S)

A moderate proportion of AYA cancer survivors are voluntarily childless, but reproductive intentions were not related to cancer type or cancer treatments. AYA survivors of older age and nonheterosexual identification were more likely to be voluntarily childless. These data support assessing reproductive intentions and tailoring reproductive care such as fertility and contraception counseling that is appropriate for a survivor's intentions.

Sex effects across the lifespan in women with multiple sclerosis

Multiple sclerosis (MS) is an autoimmune inflammatory demyelinating central nervous system disorder that is more common in women, with onset often during reproductive years. The female:male sex ratio of MS rose in several regions over the last century, suggesting a possible sex by environmental interaction increasing MS risk in women. Since many with MS are in their childbearing years, family planning, including contraceptive and disease-modifying therapy (DMT) counselling, are important aspects of MS care in women. While some DMTs are likely harmful to the developing fetus, others can be used shortly before or until pregnancy is confirmed. Overall, pregnancy decreases risk of MS relapses, whereas relapse risk may increase postpartum, although pregnancy does not appear to be harmful for long-term prognosis of MS. However, ovarian aging may contribute to disability progression in women with MS. Here, we review sex effects across the lifespan in women with MS, including the effect of sex on MS susceptibility, effects of pregnancy on MS disease activity, and management strategies around pregnancy, including risks associated with DMT use before and during pregnancy, and while breastfeeding. We also review reproductive aging and sexual dysfunction in women with MS.

Pregnancy and Motherhood Concerns Surrounding Women with Multiple Sclerosis: A Qualitative Content Analysis

Background

There is a high prevalence of multiple sclerosis (MS) among Iranian women of reproductive age. However, very few studies have been conducted in Iran to assess the experiences with and concerns about pregnancy and motherhood of such patients. The present study was conducted to better understand the experiences and concerns of women with MS about pregnancy and motherhood.

Methods

The present qualitative study was conducted from August 2016 to January 2017 among Iranian women with MS visiting the Iran MS Society in Tehran, Iran. The purposive sampling method was used to recruit the participants and the sampling was continued until data saturation. Based on the inclusion criteria, a total of 25 women with MS were recruited in the study. The data were collected by in-depth semi-structured face-to-face interviews and analyzed using the MAXQDA 10 software.

Results

The analysis of the interview data resulted in four main categories, namely "Pregnancy concerns", "Fear of failing as a parent", "Feeling of threatened fertility", and "Lack of social support". The results showed that Iranian women with MS avoided pregnancy due to the negative effects of the disease on their physical abilities and on life in general. They were also concerned about possible infertility, the effect of MS medications on their menstrual cycle, and the limitations of infertility treatments due to the presence of MS. These concerns led them to postpone pregnancy and lose time or opt for voluntary childlessness and consequently miss out on the experience of motherhood.

Conclusion

MS poses a serious challenge to women who consider getting pregnant and wish to experience motherhood. Health care professionals should support such patients to overcome their concerns and indecisiveness by providing appropriate information and counseling.

Pregnancy-related issues in women with multiple sclerosis: an evidence-based review with practical recommendations

Objective: To review the current evidence regarding pregnancy-related issues in multiple sclerosis (MS) and to provide recommendations specific for each of them. Research design and methods: A systematic review was performed based on a comprehensive literature search. Results: MS has no effect on fertility, pregnancy or fetal outcomes, and pregnancies do not affect the long-term disease course and accumulation of disability. There is a potential risk for relapse after use of gonadotropin-releasing hormone agonists during assisted reproduction techniques. At short-term, pregnancy leads to a reduction of relapses during the third trimester, followed by an increased risk of relapses during the first three months postpartum. Pregnancies in MS are not per se high risk pregnancies, and MS does not influence the mode of delivery or anesthesia unless in the presence of significant disability. MRI is not contraindicated during pregnancy; however, gadolinium contrast media should be avoided whenever possible. It is safe to use pulse dose methylprednisolone infusions to manage acute disabling relapses during pregnancy and breastfeeding. However, its use during the first trimester of pregnancy is still controversial. Women with MS should be encouraged to breastfeed with a possible favorable effect of exclusive breastfeeding. Disease-modifying drugs can be classified according to their potential for pregnancy-associated risk and impact on fetal outcome. Interferon beta (IFNβ) and glatiramer acetate (GA) may be continued until pregnancy is confirmed and, after consideration of the individual risk-benefit if continued, during pregnancy. The benefit of continuing natalizumab during the entire pregnancy may outweigh the risk of recurring disease activity, particularly in women with highly active MS. GA and IFNβ are considered safe during breastfeeding. The use of natalizumab during pregnancy or lactation requires monitoring of the newborn. Conclusions: This review provides current evidence and recommendations for counseling and management of women with MS preconception, during pregnancy and postpartum.

Neuroimmunologic disorders in pregnancy

Pregnancy influences the course of neuroimmunologic conditions, which include multiple sclerosis (MS), neuromyelitis optica spectrum disorder, and autoimmune encephalitis. The outcomes differ significantly for each disorder, reflecting the impact of hormonal changes, T-cell subsets, and placental factors on disease pathogenesis. In recent years, numerous data have emerged regarding MS activity throughout pregnancy and postpartum. Historically, the misconception that pregnancy worsens MS outcomes led patients to abstain from childbearing. Now, more women with these disorders, empowered by up-to-date information and better baseline disease control, are choosing to conceive. Nevertheless, the management of MS and related disorders in the pregnancy and postpartum period is complicated and requires a nuanced approach. Since standardized treatment guidelines around pregnancy are currently lacking, neurologists, together with obstetricians, must engage patients in a shared decision-making process that weighs the benefits to the mother and risks to the fetus. This chapter outlines the pathophysiology of neuroimmunologic disorders during pregnancy and postpartum, the impact of these diseases on childbearing, including fertility, pregnancy, delivery, and peurperium, as well as existing recommendations for treatment.

Maternal disability and risk for pregnancy, delivery, and postpartum complications: a systematic review and meta-analysis

BACKGROUND

Women with disabilities are increasingly becoming pregnant, and growing evidence suggests maternal disability may be associated with increased risk for perinatal complications.

OBJECTIVE

A systematic review and meta-analysis were undertaken to examine the association between maternal disabilities and risk for perinatal complications.

STUDY DESIGN

Medline, CINAHL, EMBASE, and PsycINFO were searched from inception to July 2018 for full-text publications in English on pregnancy, delivery, and postpartum complications in women with any disability and those with physical, sensory, and intellectual and developmental disabilities specifically. Searches were limited to quantitative studies with a comparison group of women without disabilities. Reviewers used standardized instruments to extract data from and assess the quality of included studies. Pooled odds ratios and 95% confidence intervals were generated using DerSimonian and Laird random effects models for outcomes with data available from ≥3 studies.

RESULTS

The review included 23 studies, representing 8,514,356 women in 19 cohorts. Women with sensory (pooled unadjusted odds ratio, 2.85, 95% confidence interval, 0.79-10.31) and intellectual and developmental disabilities (pooled unadjusted odds ratio, 1.10, 95% confidence interval, 0.76-1.58) had elevated but not statistically significant risk for gestational diabetes. Women with any disability (pooled unadjusted odds ratio, 1.45, 95% confidence interval, 1.16-1.82) and intellectual and developmental disabilities (pooled unadjusted odds ratio, 1.77, 95% confidence interval, 1.21-2.60) had increased risk for hypertensive disorders of pregnancy; risk was elevated but not statistically significant for women with sensory disabilities (pooled unadjusted odds ratio, 2.84, 95% confidence interval, 0.85-9.43). Women with any (pooled unadjusted odds ratio, 1.31, 95% confidence interval, 1.02-1.68), physical (pooled unadjusted odds ratio, 1.60, 95% confidence interval, 1.21-2.13), and intellectual and developmental disabilities (pooled unadjusted odds ratio, 1.29, 95% confidence interval, 1.02-1.63) had increased risk for cesarean delivery; risk among women with sensory disabilities was elevated but not statistically significant (pooled unadjusted odds ratio, 1.28, 95% confidence interval, 0.84-1.93). There was heterogeneity in all analyses, and 13 studies had weak-quality ratings, with lack of control for confounding being the most common limitation.

CONCLUSION

Evidence that maternal disability is associated with increased risk for perinatal complications demonstrates that more high-quality research is needed to examine the reasons for this risk and to determine what interventions could be implemented to support women with disabilities during the perinatal period.

Reproductive history of the Danish multiple sclerosis population: A register-based study

Background:

A diagnosis of multiple sclerosis (MS) may impact the choice of parenthood.

Objective:

To investigate the number of live births, abortions and ectopic pregnancies among persons with MS.

Methods:

From the Danish Multiple Sclerosis Registry, we extracted data from all persons diagnosed with MS from 1960 to 1996 and matched each MS person with four reference persons. We used a negative binomial regression model for the live births and Poisson regression model for abortions and ectopic pregnancies. The total fertility rate (TFR) during 1960–2016 and the annual number of live births in the MS population were analysed.

Results:

Persons with MS had fewer children than reference persons. Fewer women with MS had elective abortions after diagnosis (incidence rate ratio (IRR) = 0.88; 95% confidence interval (CI) = 0.78–1.00) than reference persons. There was no difference regarding the number of elective abortions, spontaneous abortions or ectopic pregnancies after onset. The TFR was lower for women with MS than for reference persons, and the number of annual live births by MS persons increased during 1960–2016.

Conclusion:

MS seems to considerably impact reproductive choices, especially after clinical diagnosis, resulting in the MS population having fewer children than the general population.

Women's Health: Contemporary Management of MS in Pregnancy and Post-Partum

Multiple sclerosis (MS) primarily affects women in childbearing age and is associated with an increased risk of adverse post-partum outcomes. Relapses and now fetal exposure to disease modifying treatments in the early phase of pregnancy and thereafter are of concern. Safe and effective contraception is required for women who wish to delay or avoid pregnancy while on disease-modifying treatments. Counseling and planning is essential to assess the risk of both fetal and maternal complications, particularly now in the era of highly efficient and riskier therapies. The purpose of this review is to provide a practical framework using the available data surrounding pregnancy in MS with the goal of optimizing outcomes during this phase in MS.

The Risk of Elective Abortion in Women With Crohn's Disease and Ulcerative Colitis: A Nationwide Cohort Study

BACKGROUD

Women with inflammatory bowel disease (IBD) might have an increased tendency to choose an elective abortion due to a fear that their fetus could be harmed by use of medications, disease flares during pregnancy, or for genetic reasons. We examined the risk of elective abortions in women with ulcerative colitis (UC) and Crohn's disease (CD) compared with women without IBD.

METHODS

This nationwide cohort study, based on Danish health registries, comprises all registered pregnancies from 1996 through 2015. The 2 exposed groups constituted pregnancies of women with UC or CD, and the unexposed group constituted all pregnancies of women without IBD. Our outcome was elective abortion by maternal request up until the end of the 12th completed week of gestation. We used logistic regression models and calculated the odds ratio (OR) for an elective abortion, controlling for confounders.

RESULTS

The overall prevalence rates of elective abortions in women with UC and CD and without IBD were 12.4% (898 elective abortions/7250 pregnancies), 14.9% (978 elective abortions/6559 pregnancies), and 16.9% (285,251 elective abortions/1,691,857 pregnancies), respectively. In women with UC and CD, the adjusted ORs for an elective abortion (95% confidence interval) were 0.80 (0.74-0.86) and 0.96 (0.89-1.04), respectively.

CONCLUSIONS

Pregnant women with IBD are not more likely to choose an elective abortion compared with women without IBD. These results are reassuring as they suggest that women with IBD are not so worried about a negative impact of their disease, disease activity, or medications that they would choose to terminate a pregnancy.

Factors interfering with parenthood decision-making in an Italian sample of people with multiple sclerosis: an exploratory online survey

BACKGROUND

Little is known about the influence of multiple sclerosis (MS) diagnosis on parenthood attitude in people with MS (pwMS).

OBJECTIVE

To investigate the impact of diagnosis, clinical features and external disease-related influences on parenthood decision-making in Italian pwMS.

METHODS

A web-based survey was posted on SMsocialnetwork.com to investigate clinical status, parenthood desire, influences on family planning, pregnancy outcomes, abortions and adoptions of pwMS.

RESULTS

33/395 respondents never wanted to become parent because of MS ("anti-parenthood after diagnosis"). 362 declared to be in favor of parenthood. 51% pwMS having a child by the survey time had already received the MS diagnosis at first childbirth. The frequency of a second child in pwMS after diagnosis was 38% compared to 67% in people without yet MS diagnosis. 16% of pwMS were discouraged to become parent after diagnosis, mainly by medical personnel. In 71% of respondents, diagnosis did not delay the decision to become parent and only 39% were counseled by treating physician to plan pregnancy. Patients' distribution according to the clinical phenotype (exclusively relapsing vs exclusively progressive) showed a higher proportion of progressive patients in the "anti-parenthood after diagnosis" subgroup.

CONCLUSION

MS diagnosis impacted dramatically on the life project of 7% of pwMS that decided not to have children because of the disease and in pro-parenthood pwMS impacted especially on having the second child. Only a minority was counseled to plan pregnancy. A worse disease course driving to a progressive phenotype at survey time might have negatively impacted on parenthood desire.

Management of pregnancy-related issues in multiple sclerosis patients: the need for an interdisciplinary approach

Multiple sclerosis (MS) is a demyelinating and neurodegenerative disease of the central nervous system (CNS), most probably autoimmune in origin, usually occurring in young adults with a female/male prevalence of approximately 3:1. Women with MS in the reproductive age may face challenging issues in reconciling the desire for parenthood with their condition, owing to the possible influence both on the ongoing or planned treatment with the possible consequences on the disease course and on the potential negative effects of treatments on foetal and pregnancy outcomes. At MS diagnosis, timely counselling should promote informed parenthood, while disease evolution should be assessed before making therapeutic decisions. Current guidelines advise the discontinuation of any treatment during pregnancy, with possible exceptions for some treatments in patients with very active disease. Relapses decline during pregnancy but are more frequent during puerperium, when MS therapy should be promptly resumed in most of the cases. First-line immunomodulatory agents, such as interferon-β (IFN-β) and glatiramer acetate (GA), significantly reduce the post-partum risk of relapse. Due to substantial evidence of safety with the use of GA during pregnancy, a recent change in European marketing authorization removed the pregnancy contraindication for GA. This paper reports a consensus of Italian experts involved in MS management, including neurologists, gynaecologists and psychologists. This consensus, based on a review of the available scientific evidence, promoted an interdisciplinary approach to the management of pregnancy in MS women.