MS, fertility & pregnancy – a multidisciplinary perspective

Questions:

Do you have any advice or precautions for men with multiple sclerosis on disease modifying therapies whose partners wish to get pregnant?

Do you have any advice for men taking Teriflunomide if they are trying for a family - I recently asked a few colleagues and the advice given was varied?

Answer:
Disease modifying treatments and family planning in men with MS

Teriflunomide: No restrictions are required for men taking teriflunomide.

Cladribine: Men who have received cladribine treatment should take additional precautions to avoid
fathering a pregnancy for 6 months after their last dose

Fertility: There is no evidence of concern related to male fertility alongside disease modifying
treatments in multiple sclerosis on the date of this webinar. However, there is a general lack of evidence in this area.

Further information:

MS Society link:
What to know about MS and pregnancy

Paper:
Effect of Multiple Sclerosis and Its Treatments on Male Fertility: Cues for Future Research.

*Please note that all session and slide content are the views of the speakers, not the MS Academy.
The content of the recording is the speaker's personal opinion at the time of recording. Due to the
everchanging situation, advice given at the time of recording is subject to change.

MS, fertility and pregnancy: A multidisciplinary perspective

MS affects more women than men, and is usually diagnosed during child bearing years. This makes fertility and pregnancy important topics in MS care.

During a recent Neurology Academy webinar, a panel of specialist healthcare professionals busted common myths, spoke about the importance of pre-conception counselling, and advocated for holistic care and shared decision-making.

Understanding MS and fertility

For years, said Daisy Cam, an MS specialist nurse in Sheffield, women with MS were discouraged from having children. “Luckily, this has changed, but there are still a lot of common fears,” she added.

People are scared pregnancy will make their MS worse, that they won’t be able to breastfeed, or that they will pass the condition on to their children. Some are concerned they will find it difficult to conceive, or will have to deliver via caesarean.

Quoting researcher and person living with MS, Rachel Horne, Daisy said: “Yes, there are challenges, and support is key, but having MS doesn't mean you can't be a great parent or should be discouraged from this major life experience.”

There is no evidence, she went on, to suggest that MS or disease modifying therapies (DMT) affect fertility.

Dr Paarul Prinja, consultant acute and obstetric physician at The Royal Wolverhampton NHS Trust, said they may experience a delay to conception, due to MS symptoms such as sexual dysfunction or fatigue. “It is really important to ask the question,” she added, “do not delay referral to fertility services if there is no conception after a year.”

While some women with complex disease will need consultant-led care and anaesthetic review, living with MS does not necessarily make a pregnancy high-risk. Caesarean delivery is a choice, there is no need for extra growth scans, and women do not need to take blood thinners.

While there is a slightly increased chance of the child of a woman with MS developing the condition, “it is not hugely higher”, said Daisy. She added that vitamin D supplementation and not smoking can reduce the risk.

Disease activity in pregnancy

One of the biggest questions people have, said Dr Kate Petheram, consultant neurologist in Sunderland, is does pregnancy affect MS activity.

Evidence shows that annualised relapse rates (ARR) fall during pregnancy, with a period of increased risk post-partum. “That is what we are trying to avoid,” said Kate.

Risk factors for post-partum relapses include a higher ARR before and during pregnancy, and a higher EDSS at pregnancy onset. Factors associated with reduced risk include breastfeeding and more stable and optimised disease pre-pregnancy.

DMTs and pregnancy

DMT discontinuation is an important consideration, and one that varies according to the drug, the patient, and the circumstances.

Kate said: “What we're doing more increasingly in the MS world is to use real-world evidence to weigh the risks and benefits for the patient and the fetus. This is evolving case-by-case, and there is an increasing amount of guidance to help us do this. We don't have to be making these decisions completely on our own."

Useful publications include the Association of British Neurologists’ (ABN) UK consensus on pregnancy in MS,[1] which is currently being updated, and anti-CD20 therapies in pregnancy and breastfeeding review and guidelines.[2]

“One of the most useful things I give patients is a leaflet produced by the MS Pregnancy Register group, which summarises the UK ABN consensus guidelines,” Kate explained. “These are also available on a new website, pregnancy.ms.”

Regarding DMTs and breastfeeding, Kate said interferons and glatiramer acetate could be continued, while orals are generally not recommended. “All monoclonals are large molecules which are inactive when they are orally absorbed,” she added.

Managing MS and pregnancy

Pre-conception counselling and holistic, multidisciplinary care throughout pregnancy are essential, said Paarul.

“The leading cause of maternal mortality in the postnatal period in the UK is suicide,” she said. “This is harrowing. At every encounter we need to ask about mental health, and signpost them to perinatal mental health services or suggest medication.”

Antidepressants such as SSRIs, SNRIs, and tricyclics can all be used during pregnancy, provided the risks and benefits have been considered, she added.

“With antidepressants, there's no association with miscarriage, preterm delivery, or low birth weight.” There may be a slightly increased risk of persistent pulmonary hypertension in the newborn, but it is unclear whether this is a drug effect or due to multiple confounders.

Teams should also “keep an open mind” regarding alternative diagnosis, consider comorbidities, and ask patients about red flags signs and symptoms. “Medical problems in pregnancy, sadly, are on the increase, and vague symptoms can be an early presentation of these,” Paarul added.

Most women find their symptoms settle during pregnancy, with the decreased risk of relapse. Some symptoms, however, overlap with those of pregnancy, and so tend to get worse. These include urinary tract infections, constipation, gastro-oesophageal reflux disease, and back pain.

Reduced mobility, due to MS or symphysis pubis dysfunction, for example, can increase the risk of venous thromboembolism – which is the leading cause of maternal mortality. Where MS teams have concerns, they should liaise with obstetrics, as the woman may need low molecular weight heparin prophylaxis.

MS does not increase the risk of pre-eclampsia, or obstetric haemorrhage.

Symptom management

Moving on to talk about symptom management medications, Paarul said it was very important to ensure women had accurate information about what is safe during pregnancy.

“We really need to reassure women that simple analgesia, the smallest dose for the shortest period of time, is the best thing to do.” Paracetamol can be used during pregnancy and breastfeeding, she added. Non-steroidal anti‐inflammatory drugs (NSAIDs), at the lowest dose for the shortest time, can be taken until 32 weeks, and during breastfeeding.

As in most cases of symptom management medications, it is important to understand the evidence, balance the risks and benefits, and engage in shared decision making. With drugs like baclofen and gabapentin, for example, there may be an opportunity to minimise exposure while retaining therapeutic effect.

“My practice is: what is the risk versus the benefit? Is there a possibility that we can reduce the dose, or simply avoid it in the first trimester? This is where pre-conception counselling is so important,” said Paarul.

Conclusion

While MS presents unique challenges, with the right information, planning, and multidisciplinary support, women can make informed choices and experience healthy pregnancies.

[1] Dobson, R., Dassan, P., et al. (2019). UK consensus on pregnancy in multiple sclerosis:‘Association of British Neurologists’ guidelines. Practical neurology, 19(2), 106-114.

[2] Dobson, R., Rog, D., et al. (2023). Anti-CD20 therapies in pregnancy and breast feeding: a review and ABN guidelines. Practical neurology, 23(1), 6-14.