In Vitro Fertilization Is Successful in Women With Ulcerative Colitis and Ileal Pouch Anal Anastomosis

Inflammatory Bowel Disease and Reproductive Health: A Focus on Pregnancy Planning and Outcomes

Reproductive counseling is crucial for women's health, especially for those with inflammatory bowel disease (IBD), which often affects younger patients during their childbearing years. Patients with IBD need special considerations when planning for pregnancy. Preconception counseling is important as it helps patients make informed decisions about pregnancy and allows for optimal management of IBD before, during, and after pregnancy. In this review, we aim to provide guidance for managing and treating patients with IBD throughout the preconception, pregnancy, and postpartum period.

Female and Male Fertility after Colectomy and Reconstructive Surgery in Inflammatory Bowel Diesase: A National Cohort Study from Sweden

BACKGROUND AND AIMS

Colectomy and reconstruction in patients with inflammatory bowel disease [IBD] may adversely affect fertility, but few population-based studies on this subject are available.

METHODS

Fertility was assessed in 2989 women and 3771 men with IBD and prior colectomy during 1964-2014, identified from the Swedish National Patient Register, and in 35 092 matched individuals.

RESULTS

Reconstruction with ileoanal pouch anastomosis [IPAA] was as common as ileorectal anastomosis [IRA] in ulcerative colitis [UC] and IBD-unclassified [IBD-U] but rare in Crohn's disease [CD]. Compared with the matched reference cohort, women with IBD had lower fertility overall after colectomy (hazard ratio [HR] 0.65, confidence interval [CI] 0.61-0.69), with least impact with leaving the rectum intact [HR 0.79, CI 0.70-0.90]. Compared with colectomy only, fertility in female patients remained unaffected after IRA [HR 0.86, CI 0.63-1.17 for UC, 0.86, CI 0.68-1.08 for IBD-U and 1.07, CI 0.70-1.63 for CD], but was impaired after IPAA, especially in UC [HR 0.67, CI 0.50-0.88], and after completion proctectomy [HR 0.65, CI 0.49-0.85 for UC, 0.68, CI 0.55-0.85 for IBD-U and 0.61, CI 0.38-0.96 for CD]. In men, fertility was marginally reduced following colectomy [HR 0.89, CI 0.85-0.94], regardless of reconstruction.

CONCLUSIONS

Fertility was reduced in women after colectomy for IBD. The least impact was seen when a deviated rectum was left intact. IRA was associated with no further reduction in fertility, whereas proctectomy and IPAA were associated with the strongest impairment. IRA therefore seems to be the preferred reconstruction to preserve fertility in selected female patients. Fertility in men was only moderately reduced after colectomy.

Evaluation and management of ileal pouch-anal anastamosis (IPAA) complications in pregnancy, and the impacts of an IPAA on fertility

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) remains the preferred surgical option for medically refractory ulcerative colitis. Management of individuals with an IPAA prior to and during pregnancy presents challenges that can have serious consequences. Infertility, mechanical obstructive and inflammatory pouch complications are frequently encountered in pregnant women with an IPAA. Mechanical obstructions occur due to a variety of underlying aetiologies, including stricturing disease, adhesions and pouch twists. Conservative management of such obstructions often results in resolution of symptoms without a need for endoscopic or surgical intervention, although endoscopic decompression may be attempted in isolation or as a bridge to definitive surgical intervention. Parenteral nutrition, and early delivery, may also be necessary. Faecal calprotectin and intestinal ultrasound, both of which are accurate in pregnancy, are useful in the setting of suspected inflammatory pouch complications, in some circumstances allowing for avoidance of pouchoscopy. Penicillin-based antimicrobials can be considered first line in pregnancy for the management of pouchitis and pre-pouch ileitis, and biologics can be safely instituted in the setting of refractory disease or suspected Crohn's disease-like inflammation of the pouch or pre-pouch ileum. Pragmatism, clear patient communication and multidisciplinary discussion are essential in approaching pregnant women with complications of an IPAA, particularly given the lack of definitive evidence to guide therapeutic decisions.

The Impact of Late Follicular Phase Progesterone Elevation on Cumulative Live Birth Rate and Embryo Quality in 4072 Freeze-All Cycles

Late follicular phase progesterone elevation during in vitro fertilization impedes embryo implantation. It is unclear whether late follicular phase progesterone elevation still has a negative effect on cumulative live births and embryo quality when a freeze-all strategy is adopted. Data from a total of 4072 patients were reviewed. All patients used the freeze-all strategy. Multivariate regression analyses were used to assess the association of progesterone levels with both cumulative live birth and embryo quality. There was no significant difference in the cumulative live birth rate between the groups with progesterone level <1.5 ng/mL and ≥1.5 ng/mL. The progesterone level was not associated with cumulative live birth and embryo quality.

Fertility and assisted reproductive technologies outcomes of women with non-surgically managed inflammatory bowel diseases: a systematic review

BACKGROUND AND AIM

In view of their frequent onset during childbearing years, the impact of inflammatory bowel diseases (IBD) on reproductive health is of important concern to young women and to the IBD physician. This study aims to assess the fertility and assisted reproductive technologies outcomes in non-surgically treated IBD female.

METHODS

A systematic review was conducted using MEDLINE, SCOPUS and EMBASE (until March 2022) to identify studies assessing fertility and assisted reproductive technologies outcomes in women with non-operated IBD, compared to non-IBD patients. Two reviewers independently selected studies, assessed risk of bias and extracted study data.

RESULTS

A total of 14 studies encompassing 18 012 patients with ulcerative colitis (UC) and 14 353 patients with Crohn's disease (CD) were included for analysis. The fertility rate in UC patients and in the general population was comparable, but UC patients tended to have fewer children, mainly by choice. On the contrary, the fertility of CD patients appeared to be reduced. Although a deliberate component cannot be not excluded, the disease itself could affect fertility. Disease activity was associated with reduced fertility in both UC and CD patients. In CD, the colonic involvement of the disease and perianal damage could be associated with subfertility, but data are less consistent. According to the only study reporting the assisted reproductive technologies outcomes, pregnancy rates after in vitro fertilization in subfertile non-operated UC patients and non-IBD patients were similar.

CONCLUSION

There is low-quality evidence from observational studies that patients with CD and relapsing UC may have impaired fertility. After assisted reproductive technologies, pregnancy rates of subfertile nonoperated UC patients were similar to those of the general population, although this observation requires further scrutiny in larger studies that should include UC and CD patients.

Ovarian reserve and IVF outcomes in patients with inflammatory bowel disease: A systematic review and meta-analysis

Background

Inflammatory bowel disease (IBD) mainly affects people during reproductive age. However, it is unclear whether IBD might be associated with impaired ovarian reserve in female patients or with in vitro fertilization (IVF) outcomes.

Methods

This systematic review and meta-analysis included articles from inception to May, 2022. Random-effect model was applied to calculate the standardized mean differences (SMDs) and odds ratios (ORs) and their 95% confidence intervals (95%CIs). Studies comparing the ovarian reserve or IVF outcomes of patients with IBD with the population were considered. To be included in this study, necessary measurements such as OR, relative risk (RR), SMD or hazard ratio (HR) or any necessary information to calculate them were provided in the articles. Letters, case reports, review articles including meta-analyses and expert opinions were excluded. For different articles studying the same population, the article with larger scale was selected.

Findings

We included in our analysis 9 studies and data from 2386 IBD records and matched controls. Comparing with women without IBD, women with IBD had lower anti-mullerian hormone (AMH) levels (SMD = -0.38, 95%CI: -0.67, -0.09); (I2 = 79.0%, p = 0.000). Patients with IBD of different ages showed distinct ovarian reserves, with patients below 30 years old not showing any decline in ovarian reserve compared to the control group (SMD = -0.56, 95%CI: -2.28, 1.16); (I2 = 96.3%; p = 0.000), while patients with IBD over 30 years old (SMD = -0.75, 95%CI: -1.07, -0.43); (I2 = 0.0%; p = 0.608) showed a decline compared to control group. Patients with IBD in remission stage had similar ovarian reserves to population (SMD = -0.10, 95%CI: -0.32, 0.12); (I2 = 0.0%; p = 0.667), while patients in active stage showed an impaired ovarian reserve (SMD = -1.30, 95%CI: -1.64, -0.96); (I2 = 0.0%; p = 0.318). Patients with IBD showed a pregnancy rate after receiving IVF treatment comparable to the control population (OR = 0.87, 95%CI: 0.55, 1.37); (I2 = 70.1%, p = 0.035).

Interpretation

The result of this study suggest that IBD may reduce reproductive age women's ovarian reserve and IVF treatment might help pregnancy outcomes in patients with impaired fertility. These results should be further validated in additional studies given the heterogeneity and quality of the studies included.

Funding

This study was supported by the National Natural Science Foundation of China (No. 81671423), National Key Research and Development Program of China (No. 2016YFC1000603), 2020 Shenyang Science and Technology Plan Program (No. 20-205-4-006), Scientific and Technological Talents Applied Technology Research Program of Shenyang (No. 18-014-4-56).

Gastroenterology team members' knowledge and practices with fertility therapy for women with inflammatory bowel disease

INTRODUCTION

Fecundity may be reduced in women with active inflammatory bowel disease (IBD) or prior IBD-related surgery, and these women may require assisted reproductive technology (ART). There are no guidelines for women with IBD to outline referral criteria for ART.

METHODS

We performed a prospective, multicentre, international questionnaire of gastroenterologists, gastroenterology trainees, and IBD nurses. The primary outcome was to establish clinical practices and fertility therapy referral patterns among gastroenterology team members. We hypothesised that the lack of knowledge and awareness may delay or prevent initiation of fertility consultation referrals.

DISCUSSION

Of 182 participants, most had never initiated a referral for fertility therapy (69.8%), and of respondents who do initiate referrals, 50% wait until the patient has been unsuccessfully attempting conception for 12 months. Participants were significantly more likely to initiate a fertility therapy referral if they believed ART was effective (p = 0.038), not impeded by IBD-related surgery (p = 0.053), and if they had access to a dedicated IBD-pregnancy clinic (p = 0.027). Superior pregnancy knowledge was predictive of a greater likelihood of fertility therapy referrals (p = 0.037). All participants thought they had inadequate knowledge about ART in IBD, and 96.2% expressed desire to improve their knowledge.

CONCLUSION

Gastroenterology team members infrequently initiate referrals for fertility therapy consultation in women with IBD, increasing their risk of remaining childless. Implementation of dedicated IBD pregnancy clinics and targeted education programmes to increase awareness of ART in women with IBD might increase referral rates and reduce infertility.

Female reproductive health and inflammatory bowel disease: A practice-based review

Inflammatory bowel diseases, namely ulcerative colitis and Crohn's disease, occur worldwide and affect people of all ages, with a high impact on their quality of life. Sex differences in incidence and prevalence have been reported, and there are also gender-specific issues that physicians should recognize. For women, there are multiple, important concerns regarding issues of body image and sexuality, menstruation, contraception, fertility, pregnancy, breastfeeding and menopause. This practice-based review focuses on the main themes that run through the life of women with inflammatory bowel diseases from puberty to menopause. Gastroenterologists who specialize in inflammatory bowel diseases and other physicians who see female patients with inflammatory bowel diseases should provide support for these problems and offer adequate therapy to ensure that their patients achieve the same overall well-being and health as do women without inflammatory bowel diseases.

Assisted Reproductive Technology in Crohn's Disease and Ulcerative Colitis: A Systematic Review and Meta-Analysis

INTRODUCTION

Infertility may occur in women with Crohn's disease (CD) and ulcerative colitis (UC), especially after surgery such as ileal pouch-anal anastomosis (IPAA). Assisted reproductive technology (ART) may be an option, but the safety and efficacy in this setting has been based on small cohorts to date. We performed a systematic review and meta-analysis to address this data gap.

METHODS

A systematic review and random-effects meta-analysis was performed until May 2020. The primary outcomes were pregnancy and live birth rates per cycle of ART.

RESULTS

Eleven studies met inclusion criteria for the systematic review and 4 for the meta-analysis. Compared with the general population, women with CD (with and without previous surgery) had no difference in pregnancy rates (odds ratio [OR] = 0.69, 95% confidence interval [CI]: 0.45-1.05) but had reduced live births (OR = 0.67, 95% CI: 0.53-0.85) per cycle of ART. ART live birth rates are not reduced in women with medically managed CD; however, they are 49%-71% lower after CD-related surgery. Women with UC had no difference in both pregnancy rates (OR = 0.99, 95% CI: 0.63-1.55) and live birth rates (OR = 0.88, 95% CI: 0.67-1.17); however, live birth rates were reduced after IPAA failure (hazard ratio = 0.36, 95% CI: 0.14-0.92). Two studies did not identify any significant safety signals.

DISCUSSION

ART is safe and effective in patients with UC and medically managed CD, with pregnancy and live birth rates similar to that of the general population. However, within the limitations of the available literature, current data suggest that efficacy is reduced in women with CD-related surgery and IPAA failure. Greater gastroenterologist awareness of ART is needed to facilitate timely fertility therapy referral when indicated, particularly in CD.

The Efficacy of Assisted Reproduction in Women with a Wide Spectrum of Chronic Diseases - A Review

Assisted reproductive technology (ART) treatments in women with underlying chronic diseases have become increasingly frequent. The objective of this review is to provide an overview of the literature examining the chance of having a live born child after ART in women with chronic diseases, compared to other women receiving ART. We focused on some of the most prevalent chronic diseases in women during their reproductive years, ie ulcerative colitis, Crohn's disease, rheumatoid arthritis, multiple sclerosis, epilepsy, hyperthyroidism, hypothyroidism, and diabetes mellitus. Secondly, we studied the chance of successful implantation. The literature search was performed in the database Pubmed.gov. including all studies published before October 2020. Title and abstracts of 58 papers were reviewed, 37 papers were excluded and other 8 studies were excluded after full-text evaluation. Only 13 papers were eligible for review. Results indicate that women with ulcerative colitis, Crohn's disease, rheumatoid arthritis, hyperthyroidism, and diabetes mellitus type 2 might have problems with low implantation rate or early embryo development during ART. On the contrary, the few studies on women with hypothyroidism, diabetes mellitus type 1, and epilepsy suggest an equivalent chance of a live birth compared to other women undergoing ART. A possible explanation behind these differences could reside in the disease-specific dysregulation of the innate or adaptive immune system. To our knowledge, this is the first review on ART in women with chronic diseases, and it has disclosed that the evidence in this area is indeed sparse. We encourage others to examine live birth after ART in women with chronic diseases.

Review of pregnancy in Crohn's disease and ulcerative colitis

Inflammatory bowel disease (IBD) frequently affects women of childbearing age and can have implications in pregnancy. Most women with IBD have comparable fertility with women in the general population. Fertility is reduced in women with active disease or previous ileal-pouch-anal anastomosis (IPAA) surgery and is temporarily reduced in men taking sulfasalazine. Women with IBD have an increased risk of preterm delivery, low birth weight, small-for-gestational-age infants and Cesarean section (CS) delivery, however, no increased risk of congenital abnormalities. These adverse outcomes are particularly prevalent for women with active IBD compared with those with quiescent disease. Conception should occur during disease remission to optimize maternal and fetal outcomes and reduce the risk of disease exacerbations during pregnancy. Pre-conception counseling is therefore pertinent to provide patient education, medication review for risk of teratogenicity and objective disease assessment. Most medications are safe during pregnancy and breastfeeding, with the exception of methotrexate, ciclosporin, allopurinol and tofacitinib. Delivery modality should be guided by obstetric factors in most cases; however, CS is recommended for women with active perianal disease and can be considered for women with inactive perianal disease or IPAA. In conclusion, most women with IBD have uncomplicated pregnancies. Active IBD is the predominant predictor of poor outcomes and disease exacerbations; therefore, maintenance of disease remission during and before pregnancy is crucial.

Women's Health and Ulcerative Colitis

Although ulcerative colitis affects males and females at similar rates, certain sex-specific differences influence the disease-related risks and experiences of females with ulcerative colitis. This article reviews topics that affect females with ulcerative colitis, including the impact of disease on the menstrual cycle, fertility, child bearing, sexual health, and recommendations for health care maintenance.

Infertile patients with inflammatory bowel disease have comparable in vitro fertilization clinical outcomes to the general infertile population

To assess clinical outcomes of females diagnosed with Inflammatory Bowel Disease (IBD) and infertility, which underwent in vitro fertilization (IVF) with preimplantation genetic testing for aneuploidy. (PGT-A). Retrospective cohort study comparing clinical outcomes of patients with Inflammatory bowel disease who underwent IVF with PGT-A with a subsequent euploid single embryo transfer (SET) against a matched control group. Thirty-eight patients with an IBD diagnosis were compared to 114 controls. There was no significant difference in cycle outcomes among IBD and Control cohorts [implantation rate (71.0% vs. 78.0% (p = .68)], clinical pregnancy rate [50.0% vs. 60.5% (p = .68)], live birth [62.9% vs. 73.0% (p = .06)] multiple pregnancy rate [0% vs. 1.1% (p = .25)] and clinical pregnancy loss rate [10.5% vs. 5.7% (p = .54)]. An IBD diagnosis was not found to significantly modify the odds of implantation [adjusted OR = 0.6 (95% CI -1.2 to 0.8)]. Additionally, the odds of implantation in patients with IBD were not altered by having ulcerative colitis or Crohn's disease diagnosis. (OR = 0.4 95% CI 0.1-1.9). Patients diagnosed with IBD who undergo a SET have clinical outcomes comparable to the general infertile population. Patients and physicians can be reassured that an IBD diagnosis does not impair IVF treatment outcomes.SYNOPSISInfertile patients with inflammatory bowel disease who utilized a single, euploid blastocyst transfer had IVF success rates comparable to the general infertile population.

Impact on Fertility After Failure of Restorative Proctocolectomy in Men and Women With Ulcerative Colitis: A 17-Year Cohort Study

BACKGROUND

Impact of restorative proctocolectomy failure on fertility has not been studied and is greatly relevant.

OBJECTIVE

The purpose of this study was to evaluate the impact of restorative proctocolectomy failure on birth rate in women and men, along with in vitro fertilization incidence and success.

DESIGN

This was a retrospective registry-based cohort study over 17 years.

SETTINGS

Records for parenting a child were cross-linked with patient records. In women, in vitro fertilization records were cross-linked. All data were prospectively registered.

PATIENTS

Patients of fertile age with ulcerative colitis between 1994 and 2010 were identified in Danish national databases. Patients with restorative proctocolectomy and restorative proctocolectomy failure were identified as subgroups.

MAIN OUTCOME MEASURES

Birth rate ratios and in vitro fertilization incidence and success were measured.

RESULTS

We included 11,939 women and 13,569 men with ulcerative colitis. A total of 711 women and 730 men had restorative proctocolectomy; 114 women and 90 men had failure. Birth rate in women with failure was significantly reduced compared with women without (birth rate ratio = 0.50 (95% CI, 0.29-0.82)). In men with failure, birth rate tended to be lower compared with men without (birth rate ratio = 0.74 (95% CI, 0.51-1.05)). In vitro fertilization incidence was similar with and without failure (HRs adjusted for age at start of follow-up = 0.98 (95% CI, 0.58-1.67]). In vitro fertilization success was significantly lower with failure compared with ulcerative colitis (OR adjusted for age at start of follow-up = 0.36 (95% CI, 0.4-0.92)).

LIMITATIONS

Information on patients leading up to restorative proctocolectomy failure is lacking. Failure patients may have had children during a period with pouch function. Therefore, the impact of failure may be underestimated.

CONCLUSIONS

Restorative proctocolectomy failure impairs birth rate, primarily in women. Although in vitro fertilization incidence is similar in women with and without failure, the likelihood of giving birth after in vitro fertilization is reduced. See Video Abstract at http://links.lww.com/DCR/B202. IMPACTO SOBRE LA FERTILIDAD DESPUéS DEL FRACASO DE LA PROCTOCOLECTOMíA RESTAURADORA EN HOMBRES Y MUJERES CON COLITIS ULCEROSA: UN ESTUDIO DE COHORTE DE 17 AñOS: No se ha estudiado el impacto de la falla de la proctocolectomía restauradora en la fertilidad y es muy relevante.Evaluar el impacto del fracaso de la proctocolectomía restauradora en la tasa de natalidad en mujeres y hombres, junto con la incidencia y el éxito de la fertilización in vitro.Estudio de cohorte retrospectivo basado en el registro de más de 17 años.Los registros de crianza de un niño se cruzaron con los registros de pacientes. En las mujeres, los registros de fertilización in vitro se cruzarón. Todos los datos se regitraron de forma prospectiva.Los pacientes de edad fértil con colitis ulcerosa entre 1994-2010 fueron identificados en las bases de datos nacionales danesas. Los pacientes con proctocolectomía restauradora y fracaso de la proctocolectomía restauradora se identificaron como subgrupos.Tasas de natalidad e incidencia y éxito de la fertilización in vitro.Se incluyeron 11939 mujeres y 13569 hombres con colitis ulcerosa. 711 mujeres y 730 hombres tuvieron proctocolectomía restauradora; 114 mujeres y 90 hombres tuvieron fracaso. La tasa de natalidad en las mujeres con fracaso se redujo significativamente en comparación con las mujeres sin fracaso (tasa de natalidad: 0,50; IC del 95% [0,29; 0,82]). En los hombres con fracaso, la tasa de natalidad tendió a ser más baja en comparación con los hombres sin fracaso (tasa de natalidad: 0,74; IC del 95% [0,51; 1,05]). La incidencia de fertilización in vitro fue similar con y sin falla (aHR: 0.98, IC 95% [0.58; 1.67]). El éxito de la fertilización in vitro fue significativamente menor con el fracaso en comparación con la colitis ulcerosa (aOR: 0.36 IC 95% [0.4; 0.92]).Falta información sobre los pacientes que conducen al fracaso de la proctocolectomía restauradora. Los pacientes con fracaso pueden haber tenido hijos durante un período con función de bolsa. Por lo tanto, el impacto del fracaso puede ser subestimado.El fracaso de la proctocolectomía restauradora afecta la tasa de natalidad, principalmente en mujeres. Aunque la incidencia de la fertilización in vitro es similar en las mujeres con y sin fracaso, la probabilidad de dar a luz después de la fertilización in vitro se reduce. Consulte Video Resumen en http://links.lww.com/DCR/B202. (Traducción-Dr Gonzalo Hagerman).

Reproduction and Pregnancy in Inflammatory Bowel Disease - Management and Treatment Based on Current Guidelines

Inflammatory bowel diseases (IBD) affect mainly young population. Therefore, fertility and pregnancy are important clinical issues to be considered. Generally, fertility in IBD patients is not decreased either in males or females when compared to a healthy population. Moreover, drugs used for IBD treatment do not significantly affect fertility in humans. However, prolonged treatment with sulphasalazine may reduce semen quality and cause reversible infertility. Since the disease course and a risk of pregnancy-related complications depend mainly on disease activity at the time of conception, female patients with IBD should plan their pregnancy during a remission phase. Methotrexate, mycophenolate mofetil and thalidomide are strongly contraindicated during pregnancy. Other medications used for IBD seem to be safe provided that they are administered with caution. In 2015, European Crohn's and Colitis Organisation (ECCO) published its Consensus on Reproduction and Pregnancy in IBD. However, management of IBD during the reproductive age and during pregnancy still remains controversial, since evidence-based data come mostly from retrospective studies. The aim of this paper was to discuss the issue of reproduction and pregnancy in IBD patients based on current ECCO guidelines and literature.

Surgery for Inflammatory Bowel Disease Has Unclear Impact on Female Fertility: A Cochrane Collaboration Systematic Review

Background and Aims

Surgical treatment of inflammatory bowel disease (IBD) may impair female fertility. We conducted a systematic review to determine the risk of infertility and pregnancy outcomes in women with IBD who underwent surgery.

Methods

We identified studies evaluating the impact of IBD surgery on infertility and pregnancy outcomes. Risk ratios (RR) and 95% confidence intervals (CIs) were pooled when data were presented using contingency tables. Odds ratios (OR) were pooled when raw numbers were not provided. GRADE was used to evaluate the certainty of evidence.

Results

Sixteen observational studies were included, comparing women with and without surgery, open and laparoscopic surgery and before and after surgery. All studies were of low quality. The effect of surgery on infertility at 12 months (RR 5.45, 95% CI 0.41 to 72.57) was uncertain. Similarly, the fertility effects of laparoscopic versus open surgery method were unclear (RR 0.70, 95% CI 0.38 to 1.27). The impact of IBD surgery on pregnancy outcomes should be interpreted with caution. Surgery was associated with miscarriage (OR 2.03, 95% CI 1.14 to 3.60), use of assisted reproductive technologies (RR 25.09, 95% CI 1.56 to 403.76) and caesarean section (RR 2.23, 95% CI 1.00 to 4.95), but not with stillbirth (RR 1.96, 95% CI 0.42 to 9.18), preterm birth (RR 1.91, 95% CI 0.67 to 5.48), low birth weight (RR 0.61, 95% CI 0.08 to 4.83) or small for gestational age (RR 2.54, 95% CI 0.80 to 8.01).

Conclusion

The effect of surgical therapy for IBD on rates of female infertility and pregnancy-related outcomes was uncertain due to poor quality of existing literature.

Use and Success of In Vitro Fertilisation Following Restorative Proctocolectomy and Ileal Pouch-anal Anastomosis. A Nationwide 17-year Cohort Study

BACKGROUND AND AIMS

Fertility decreases in women following restorative proctocolectomy for ulcerative colitis. The use and success of in vitro fertilisation [IVF] after restorative proctocolectomy for ulcerative colitis is not systematically studied. We aimed to estimate the use and success of in vitro fertilisation treatment in female ulcerative colitis patients, with and without restorative proctocolectomy.

METHODS

Women of fertile age [15-49 years] with restorative proctocolectomy for ulcerative colitis were compared with females with ulcerative colitis without restorative proctocolectomy. Data from the IVF registry from 1994-2010 were cross-linked with data from the National Danish Patient Registry and the Medical Birth Registry.

RESULTS

In vitro fertilisation is significantly more frequent in females with restorative proctocolectomy compared with females without restorative proctocolectomy, adjusted hazard ratio 3.2, 95% confidence interval [CI] [2.5;4.0]. The odds for having a live birth after in vitro fertilisation are no different in females with restorative proctocolectomy compared with females without restorative proctocolectomy, adjusted odds ratio 0.8, 95% CI [0.6;1.1]. The percentage of children born as a result of in vitro fertilisation is significantly higher in females with restorative proctocolectomy compared with females without restorative proctocolectomy (31.0%, 95% CI [24.1; 37.7] vs 5.0%, 95% CI [4.4; 5.6]).

CONCLUSIONS

Females with restorative proctocolectomy for ulcerative colitis have increased incidence of in vitro fertilisation by more than a factor three, the odds that a treatment results in a live birth are similar and six times more children are born as a result of in vitro fertilisation compared with females without restorative proctocolectomy.

The impact of surgical therapies for inflammatory bowel disease on female fertility

BACKGROUND

Women with inflammatory bowel disease (IBD) may require surgery, which may result in higher risk of infertility. Restorative proctocolectomy with ileal anal pouch anastomosis (IPAA) may increase infertility, but the degree to which IPAA affects infertility remains unclear, and the impact of other surgical interventions on infertility is unknown.

OBJECTIVES

Primary objective• To determine the effects of surgical interventions for IBD on female infertility.Secondary objectives• To evaluate the impact of surgical interventions on the need for assisted reproductive technology (ART), time to pregnancy, miscarriage, stillbirth, prematurity, mode of delivery (spontaneous vaginal, instrumental vaginal, or Caesarean section), infant requirement for resuscitation and neonatal intensive care, low and very low birth weight, small for gestational age, antenatal and postpartum hemorrhage, retained placenta, postpartum depression, gestational diabetes, and gestational hypertension/preeclampsia.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, and the Cochrane IBD Group Specialized Register from inception to September 27, 2018, to identify relevant studies. We also searched references of relevant articles, conference abstracts, grey literature, and trials registers.

SELECTION CRITERIA

We included observational studies that compared women of reproductive age (≥ 12 years of age) who underwent surgery to women with IBD who had a different type of surgery or no surgery (i.e. treated medically). We also included studies comparing women before and after surgery. Any type of IBD-related surgery was permitted. Infertility was defined as an inability to become pregnant following 12 months of unprotected intercourse. Infertility at 6, 18, and 24 months was included as a secondary outcome. We excluded studies that included women without IBD and those comparing women with IBD to women without IBD..

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies and extracted data. We used the Newcastle-Ottawa Scale to assess bias and GRADE to assess the overall certainty of evidence. We calculated the pooled risk ratio (RR) and 95% confidence interval (CI) using random-effects models. When individual studies reported odds ratios (ORs) and did not provide raw numbers, we pooled ORs instead.

MAIN RESULTS

We identified 16 observational studies for inclusion. Ten studies were included in meta-analyses, of which nine compared women with and without a previous IBD-related surgery and the other compared women with open and laparoscopic IPAA. Of the ten studies included in meta-analyses, four evaluated infertility, one evaluated ART, and seven reported on pregnancy-related outcomes. Seven studies in which women were compared before and after colectomy and/or IPAA were summarized qualitatively, of which five included a comparison of infertility, three included the use of ART, and three included other pregnancy-related outcomes. One study included a comparison of women with and without IPAA, as well as before and after IPAA, and was therefore included in both the meta-analysis and the qualitative summary. All studies were at high risk of bias for at least two domains.We are very uncertain of the effect of IBD surgery on infertility at 12 months (RR 5.45, 95% CI 0.41 to 72.57; 114 participants; 2 studies) and at 24 months (RR 3.59, 95% CI 1.32 to 9.73; 190 participants; 1 study). Infertility was lower in women who received laparoscopic surgery compared to open restorative proctocolectomy at 12 months (RR 0.70, 95% CI 0.38 to 1.27; 37 participants; 1 study).We are very uncertain of the effect of IBD surgery on pregnancy-related outcomes, including miscarriage (OR 2.03, 95% CI 1.14 to 3.60; 776 pregnancies; 5 studies), use of ART (RR 25.09, 95% CI 1.56 to 403.76; 106 participants; 1 study), delivery via Caesarean section (RR 2.23, 95% CI 1.00 to 4.95; 20 pregnancies; 1 study), stillbirth (RR 1.96, 95% CI 0.42 to 9.18; 246 pregnancies; 3 studies), preterm birth (RR 1.91, 95% CI 0.67 to 5.48; 194 pregnancies; 3 studies), low birth weight (RR 0.61, 95% CI 0.08 to 4.83), and small for gestational age (RR 2.54, 95% CI 0.80 to 8.01; 65 pregnancies; 1 study).Studies comparing infertility before and after IBD-related surgery reported numerically higher rates of infertility at six months (before: 1/5, 20.0%; after: 9/15, 60.0%; 1 study), at 12 months (before: 68/327, 20.8%; after: 239/377, 63.4%; 5 studies), and at 24 months (before: 14/89, 15.7%; after: 115/164, 70.1%; 2 studies); use of ART (before: 5.3% to 42.2%; after: 30.3% to 34.3%; proportions varied across studies due to differences in which women were identified as at risk of using ART); and delivery via Caesarean section (before: 8/73, 11.0%; after: 36/75, 48.0%; 2 studies). In addition, women had a longer time to conception after surgery (two to five months; 2 studies) than before surgery (5 to 16 months; 2 studies). The proportions of women experiencing miscarriage (before: 19/123, 15.4%; after: 21/134, 15.7%; 3 studies) and stillbirth (before: 2/38, 5.3%; after: 3/80: 3.8%; 2 studies) were similar before and after surgery. Fewer women experienced gestational diabetes after surgery (before: 3/37, 8.1%; after: 0/37; 1 study), and the risk of preeclampsia was similar before and after surgery (before: 2/37, 5.4%; after: 0/37; 1 study). We are very uncertain of the effects of IBD-related surgery on these outcomes due to poor quality evidence, including confounding bias due to increased age of women after surgery.We rated evidence for all outcomes and comparisons as very low quality due to the observational nature of the data, inclusion of small studies with imprecise estimates, and high risk of bias among included studies.

AUTHORS' CONCLUSIONS

The effect of surgical therapy for IBD on female infertility is uncertain. It is also uncertain if there are any differences in infertility among those undergoing open versus laparoscopic procedures. Previous surgery was associated with higher risk of miscarriage, use of ART, Caesarean section delivery, and giving birth to a low birth weight infant, but was not associated with risk of stillbirth, preterm delivery, or delivery of a small for gestational age infant. These findings are based on very low-quality evidence. As a result, definitive conclusions cannot be made, and future well-designed studies are needed to fully understand the impact of surgery on infertility and pregnancy outcomes.

Recent Advances in Fertility Preservation and Counseling for Reproductive-Aged Women with Colorectal Cancer: A Systematic Review

BACKGROUND

The incidence of colorectal cancer among reproductive-aged women is increasing. Concerns regarding future fertility are secondary only to concerns regarding survival and may significantly impact quality of life among reproductive-aged female cancer survivors. Fertility preservation counseling reduces long-term regret and dissatisfaction among cancer survivors. Health care providers counseling patients with colorectal cancer must understand the impact of cancer treatment on future reproductive potential.

OBJECTIVE

This review aims to examine the effects that colorectal cancer treatments have on female fertility and summarize existing and emerging options for fertility preservation.

DATA SOURCES

EMBASE, National Library of Medicine (MEDLINE)/PubMed, Cochrane Review Library were the data sources for this review.

STUDY SELECTION

A systematic literature review was performed using exploded MeSH terms to identify articles examining the effect of surgery, chemotherapy, and radiation, as well as fertility preservation options for colorectal cancer on female fertility. Relevant studies were included.

MAIN OUTCOME MEASURES

The primary outcome was the effect of colorectal cancer treatment on fertility.

RESULTS

There are limited data regarding the impact of colorectal surgery on fertility. The gonadotoxic effects of chemotherapy on reproductive capacity depend on age at the time of chemotherapy administration, cumulative chemotherapy, radiation dose, type of agent, and baseline fertility status. Chemotherapy-induced risks for colorectal cancers are considered low to moderate, whereas pelvic radiation with a dose of 45 to 50 Gray induces premature menopause in greater than 90% of patients. Ovarian transposition may reduce but not eliminate the damaging effect of radiation on the ovaries. Embryo and oocyte cryopreservation are considered standard of care for women desiring fertility preservation, with oocyte cryopreservation no longer being considered experimental. Ovarian tissue cryopreservation remains experimental but may be an option for select patients. The use of gonadotropin-releasing hormone agonists remains controversial and has not been definitively shown to preserve fertility.

LIMITATIONS

The limitations of this review are the lack of randomized controlled trials and high-quality studies, as well as the small sample sizes and the use of surrogate fertility markers.

CONCLUSION

Reproductive-aged women with colorectal cancer benefit from fertility preservation counseling before the initiation of cancer treatment.

Women's Health in Inflammatory Bowel Disease

About half of all inflammatory bowel disease (IBD) patients are women. It is important that physicians are aware of gender-specific needs women with IBD may have. This review covers general and specific women's health issues related to their IBD. It is intended to be practical and give a brief overview of topics including body image, menstruation, contraception, cervical cancer screening, preconception counseling, anxiety, depression, pregnancy, breastfeeding, menopause, skin exams, vaccines, laboratory monitoring and bone health.

Contemporary Management of Ulcerative Colitis

PURPOSE OF REVIEW

We discuss the newest evidence-based data on management of ulcerative colitis (UC). We emphasize risk-stratification, optimizing medical therapies, and surgical outcomes of UC.

RECENT FINDINGS

Recent medical advances include introduction of novel agents for UC. Vedolizumab, an anti-adhesion molecule, has demonstrated efficacy in moderate to severe UC. Tofacitinib, a small molecule, has also demonstrated efficacy. Data on optimization of infliximab show the superiority of combination therapy with azathioprine over monotherapy with infliximab or azathioprine alone. Data on anti-tumor necrosis factor-alpha (anti-TNF) therapeutic drug monitoring also hold promise, as do preliminary data on the dose escalation of infliximab in severe hospitalized UC. Surgical outcome data are reassuring, with new fertility data showing the effectiveness of in vitro fertilization. UC management is multi-disciplinary and changing. While novel therapies hold promise, better optimization of our current arsenal will also improve outcomes.

Updates on Women's Health Issues in Patients with Inflammatory Bowel Disease

PURPOSE OF REVIEW

Inflammatory bowel disease affects approximately 800,000 women in the USA with the peak incidence between ages 15 to 40. Thus for many females, IBD can impact nearly every stage of their life from menarche to pregnancy, menopause, and beyond. This paper will review the most recent updates on the topics of sexual health, cervical cancer screening, menstruation, fertility, contraception, and menopause.

RECENT FINDINGS

Menarche can be delayed in females especially those who are underweight, malnourished, or with active inflammatory bowel disease. Cyclical GI symptoms during a menstrual cycle are very common in women with IBD and should not be confused with flares. Overall fertility is similar to the general population unless females with IBD have had significant abdominal surgery but reassuringly this infertility appears to be restored with the use of in vitro fertilization. Discussion regarding family planning is imperative in women with IBD with a strong recommendation to consider long-acting highly effective contraceptives such as intrauterine devices or implants. Cervical cancer screening should be tailored in women on immunosuppressive medications and all women under 26 years of age should be advised to receive the human papilloma virus vaccination. As gastroenterologists will have longitudinal relationships with their female IBD patients, they must be knowledgeable about sex-specific issues during each stage of life from puberty to after menopause to optimize their patient's care.

Surgical options in the treatment of ulcerative colitis

Children and young adults with ulcerative colitis tend to present with more extensive colonic disease than an adult population. The need for surgical intervention in the pediatric population with ulcerative colitis occurs earlier after diagnosis and has a greater incidence than a comparably matched adult population with an estimated need for colectomy at 5 years following diagnosis of 14-20%. Perhaps, even more than the adult population, there is a desire to restore intestinal continuity for the pediatric patient to achieve as healthy and normal quality of life as possible. With surgery playing such a prominent role in the treatment of ulcerative colitis in this age group, an understanding of the surgical treatment options that are available is important. The surgeon's awareness of the complexities of the different operations associated with proctocolectomy and reestablishing intestinal continuity may help to avoid early complications and minimize the risk of less than ideal long-term outcomes.

The Efficacy of Assisted Reproduction in Women with Inflammatory Bowel Disease and the Impact of Surgery-A Nationwide Cohort Study

BACKGROUND

In this study, we analyze the chance of a live birth and the impact of inflammatory bowel disease surgery in women with Crohn's disease (CD) or ulcerative colitis (UC) who have undergone assisted reproductive technology (ART) treatments.

METHODS

This is a nationwide cohort study based on the Danish health registries. We compare all women with and without CD or UC who received a first time ART treatment from January 1, 1994 to June 30, 2012 with follow-up until December 31, 2013. Our outcome was live birth per woman within 18 months after the first ART treatment. We adjusted for multiple covariates and looked specifically at CD and UC surgeries before ART.

RESULTS

In all, 381 women with UC, 158 women with CD, and 50,321 women without inflammatory bowel disease received first time ART treatments. In women with UC, the adjusted odds ratio (OR) of a live birth was 0.82 (95% confidence interval [CI], 0.57-1.17). In women with CD, the adjusted OR of a live birth was 0.58 (95% CI, 0.32-1.03). In women with CD having previous CD surgery versus no CD surgery, the adjusted OR of a live birth was significantly decreased (0.29, 95% CI, 0.13-0.65). In women with UC with previous UC surgery, the similar OR was 0.81 (95% CI, 0.47-1.40).

CONCLUSIONS

In women with CD surgery, the chance of a live birth within 18 months after initiation of ART treatment was significantly decreased. This knowledge should help patients make decisions regarding pregnancy planning.

Optimizing Inflammatory Bowel Disease for Successful In Vitro Fertilization

We present a nulliparous woman with mild to moderate ulcerative colitis (UC) and multiple failed cycles of in vitro fertilization (IVF) in whom we achieved a successful, viable pregnancy following clinical and endoscopic UC remission. Infertile patients with inflammatory bowel disease who have failed multiple cycles of IVF should try to achieve clinical remission and mucosal healing (absence of erosions or ulcers) prior to reattempting conception. Furthermore, deficiencies in vitamin B12, vitamin D, and iron should be addressed.

Factors Associated with the Success of In Vitro Fertilization in Women with Inflammatory Bowel Disease

BACKGROUND

It is unknown whether certain factors are associated with the success of in vitro fertilization (IVF) in women with inflammatory bowel disease (IBD).

AIM

This study assessed whether certain characteristics are associated with greater success of live birth following IVF.

METHODS

In a cohort study of 8684 women with IBD seen at two tertiary care centers, we identified 121 women with IBD who underwent IVF. We assessed the effect of numerous factors on likelihood of achieving live birth after IVF.

RESULTS

Seventy-one patients with ulcerative colitis (UC) and 49 patients with Crohn's disease (CD) were analyzed. Patients with UC who achieved a live birth were younger (p = 0.03), had a shorter duration of disease (p = 0.01), and were more likely to be in remission (p = 0.03) versus those who did not achieve live birth. Patients with CD who achieved live birth were younger (p < 0.001), had lower body mass index (BMI) (p = 0.02), and had lower cycle day 3 follicle-stimulating hormone levels (p = 0.02). There was no difference in likelihood of achieving live birth among patients in remission and those with mild or unknown disease status (p = 0.69), though most CD patients (79.5 %) were in remission. Prior surgery was not associated with live birth in patients with UC (p = 0.31) or CD (p = 0.62).

CONCLUSIONS

As in the general infertility population, younger patients and those with lower BMI were more likely to achieve live birth. History of surgery was not associated with live birth among IBD patients. This is important information for practitioners counseling IBD patients.

Pregnancy and the Patient with Inflammatory Bowel Disease: Fertility, Treatment, Delivery, and Complications

For many women with inflammatory bowel disease (IBD), the illness coincides with their childbearing years. IBD increases the risk of pregnancy complications and adverse pregnancy outcomes. The multidisciplinary care team should emphasize the importance of medication adherence to achieve preconception disease control and maintain corticosteroid-free remission throughout pregnancy. Medication adjustments to reduce fetal exposure may be considered on an individualized basis in quiescent disease; however, any benefits of such adjustments remain theoretic and there is risk of worsening disease activity. Mode of delivery is determined by obstetric indications, except for women with active perianal disease who should consider cesarean delivery.

Live birth and adverse birth outcomes in women with ulcerative colitis and Crohn's disease receiving assisted reproduction: a 20-year nationwide cohort study

OBJECTIVE

To examine the chance of live births and adverse birth outcomes in women with ulcerative colitis (UC) and Crohn's disease (CD) compared with women without inflammatory bowel disease (IBD) who have undergone assisted reproductive technology (ART) treatments.

METHODS

This was a nationwide cohort study based on Danish health registries, comprising all women with an embryo transfer during 1 January 1994 through 2013. The cohorts comprised 1360 ART treatments in 432 women with UC, 554 ART treatments in 182 women with CD and 148,540 treatments in 52,489 women without IBD. Our primary outcome was live births per ART treatment cycle. We controlled for multiple covariates in the analyses. Our secondary outcomes were adverse birth outcomes.

RESULTS

The chance of a live birth for each embryo transfer was significantly reduced in ART treatments in women with UC (OR=0.73, 95% CI 0.58 to 0.92), but not significantly reduced in the full model of ART treatments in women with CD (OR=0.77, 95% CI 0.52 to 1.14). Surgery for CD before ART treatment significantly reduced the chance of live birth for each embryo transfer (OR=0.51, 95% CI 0.29 to 0.91). In children conceived through ART treatment by women with UC, the OR of preterm birth was 5.29 (95% CI 2.41 to 11.63) in analyses including singletons and multiple births; restricted to singletons the OR was 1.80, 95% CI 0.49 to 6.62.

CONCLUSIONS

Our results suggest that women with UC and CD receiving ART treatments cannot expect the same success for each embryo transfer as other infertile women. Women with CD may seek to initiate ART treatment before needing CD surgery. Increased prenatal observation in UC pregnancies after ART should be considered.

The Toronto Consensus Statements for the Management of Inflammatory Bowel Disease in Pregnancy

BACKGROUND & AIMS

The management of inflammatory bowel disease (IBD) poses a particular challenge during pregnancy because the health of both the mother and the fetus must be considered.

METHODS

A systematic literature search identified studies on the management of IBD during pregnancy. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Consensus was reached on 29 of the 30 recommendations considered. Preconception counseling and access to specialist care are paramount in optimizing disease management. In general, women on 5-ASA, thiopurine, or anti-tumor necrosis factor (TNF) monotherapy for maintenance should continue therapy throughout pregnancy. Discontinuation of anti-TNF therapy or switching from combination therapy to monotherapy may be considered in very select low-risk patients. Women who have a mild to moderate disease flare while on optimized 5-ASA or thiopurine therapy should be managed with systemic corticosteroid or anti-TNF therapy, and those with a corticosteroid-resistant flare should start anti-TNF therapy. Endoscopy or urgent surgery should not be delayed during pregnancy if indicated. Decisions regarding cesarean delivery should be based on obstetric considerations and not the diagnosis of IBD alone, with the exception of women with active perianal Crohn's disease. With the exception of methotrexate, the use of medications for IBD should not influence the decision to breast-feed and vice versa. Live vaccinations are not recommended within the first 6 months of life in the offspring of women who were on anti-TNF therapy during pregnancy.

CONCLUSIONS

Optimal management of IBD before and during pregnancy is essential to achieving favorable maternal and neonatal outcomes.

Treatment of the Pregnant Patient with Inflammatory Bowel Disease

Research regarding fertility, medication safety, and pregnancy outcomes is increasing, but there are still many knowledge gaps in these areas. Women with ulcerative colitis and Crohn's disease may have decreased fertility because of voluntary childlessness and inflammatory bowel disease (IBD) surgery, and women with Crohn's disease may also have decreased ovarian reserve. Initial studies show that in vitro fertilization is a viable option, and laparoscopic ileoanal pouch anastomosis surgery improves fertility rates. Additional research is needed on the effect of disease activity on fertility and on the rates of pregnancy loss and ectopic pregnancies. We do not know how to reliably measure disease activity during pregnancy or the effect of pregnancy on the microbiome. Although immunomodulators and anti-tumor necrosis factor medications are relatively safe during pregnancy, the long-term effects of these medications on the child are unknown. The recommended mode of delivery is still debated, especially for women after ileoanal pouch anastomosis. There are multiple studies on the relative safety of immunomodulators and anti-tumor necrosis factor medications during pregnancy, and we know how to safely treat a pregnant patient with a disease flare. The best way to manage women with IBD who are pregnant or contemplating pregnancy is a multidisciplinary approach. Team members often include a gastroenterologist, a high-risk obstetrician, an infertility specialist, a colorectal surgeon, and a pediatrician with experience in caring for children of mothers with IBD. By integrating expertise from these disciplines, women with even very complex IBD should be able to have a healthy pregnancy and delivery.

Pregnancy related problems in inflammatory bowel disease

Inflammatory bowel disease (IBD) often affects the young population and is prominent in the reproductive phase of their lives. Women with IBD often experience activation or flare during pregnancy and delivery, which complicates the patients' conditions. The important effects of IBD on pregnancy outcome and the potential need for medical or surgical interventions raise concerns about pregnancy issues. Questions about fertility, pregnancy and breast feeding are often asked by patients. The aim of this review is to discuss fertility and pregnancy in inflammatory bowel disease and the safety of drugs during pregnancy and lactation. We recommend that clinicians guide patients to eliminate fear, plan conception during stable remission, and accept the individual treatment with the minimum risk, in order to obtain a good pregnancy outcome.

In Vitro Fertilization in Women With Inflammatory Bowel Disease Is as Successful as in Women From the General Infertility Population

BACKGROUND & AIMS

Inflammatory bowel disease (IBD) affects women of reproductive age, so there are concerns about its effects on fertility. We investigated the success of in vitro fertilization (IVF) in patients with IBD compared with the general (non-IBD) IVF population.

METHODS

We conducted a matched retrospective cohort study of female patients with IBD who underwent IVF from 1998 through 2011 at 2 tertiary care centers. Patients were matched 4:1 to those without IBD (controls). The primary outcome was the cumulative rate of live births after up to 6 cycles of IVF. Secondary outcomes included the proportion of patients who became pregnant and the rate of live births for each cycle.

RESULTS

Forty-nine patients with Crohn's disease (CD), 71 patients with ulcerative colitis (UC), 1 patient with IBD-unclassified, and 470 controls underwent IVF during the study period. The cumulative rate of live births was 53% for controls, 69% for patients with UC (P = .08 compared with controls), and 57% for patients with CD (P = .87 compared with controls). The incidence of pregnancy after the first cycle of IVF was similar among controls (40.9%), patients with UC (49.3%; P = .18), and patients with CD (42.9%; P = .79). Similarly, the incidence of live births after the first cycle of IVF was similar among controls (30.2%), patients with UC (33.8%; P = .54), and patients with CD (30.6%; P = .95).

CONCLUSIONS

Based on a matched cohort study, infertile women with IBD achieve a rate of live births after IVF that is comparable with those of infertile women without IBD.

Optimizing the Care and Health of Women with Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) including both ulcerative colitis and Crohn's disease is increasing worldwide. Although diagnosis is equally found in men and women, the chronicity of IBD poses a unique impact on the milestones of a woman's life. As the gastroenterologist becomes increasingly important in the health maintenance of patients with IBD, this review stresses the unique gender issues in women with IBD related to menstruation, cervical cancer, sexual health, contraception, and menopause that may affect the course of disease, treatment decisions, and quality of life.