Documentation of reproductive health counseling and contraception in women with inflammatory bowel diseases

Knowledge, Values, and Preferences Regarding Contraceptive Choices Among Women Living With Inflammatory Bowel Disease

BACKGROUND AND AIMS

Active inflammatory bowel disease (IBD) at conception is associated with adverse pregnancy outcomes. International guidelines address antenatal care, but contraception counseling and risk assessment are not addressed. Data on healthcare professionals' guidance for women with IBD regarding contraception are scarce. We aimed to describe contraceptive use, preferences, knowledge, and barriers among women with IBD.

METHODS

A 34-item questionnaire was administered to female IBD patients aged 18-45. Disease control was measured using PRO-2 and IBD-control questionnaire, and contraceptive preferences were assessed by the contraceptive features survey. Logistic regression explored associations between contraceptive use, attitudes, disease remission status, and other factors.

RESULTS

Of 338 women surveyed, 243 (74%) used some form of contraception. Oral birth control pills (28%) and barrier methods (18%) were most used but 20% used long-acting methods. Women with active disease were more likely to use long-acting contraception (23%) compared to those in remission (17%). Contraceptive priorities were effectiveness (78%), ease of use (75%), and minimal side effects (68%). Only 25% women had discussed reproductive issues with their IBD clinician, though 85% were comfortable to do so. Preferred sources for reproductive counseling were IBD nurses (79%), general practitioners (75%), IBD doctors (68%), and gynecologists (49%).

CONCLUSIONS

A quarter of women with IBD were not using any contraception, and long-acting contraceptive use was low. Women prefer effective, easy-to-use contraceptives with minimal side effects but lack knowledge on effective contraception-related issues. Better education and proactive discussions between healthcare providers and patients could improve reproductive health in women with IBD.

Sexual Dysfunction in Women with Inflammatory Bowel Disease

Background: Crohn's disease (CD) and ulcerative colitis (UC) are chronic inflammatory bowel diseases (IBDs) characterized by various clinical symptoms including abdominal pain, diarrhea, fatigue, and extraintestinal manifestations, which negatively affect a patient's quality of life. Both mainly occur in adolescence and young adulthood and therefore affect women in their sexually active period. The aim of this study was to assess the effect of IBD on female sexuality and attitudes towards contraception. Methods: A prospective cross-sectional survey study was conducted at the Medical University of Vienna, Austria. Data were collected using a self-designed questionnaire, which included questions on demographics, gynecological patient history, contraceptive choices, and fertility, as well as the Female Sexual Functionality Index (FSFI). Results: A total of 83 female patients with IBD (CD: n = 47, UC: n = 36) and 340 healthy control participants between the ages of 18 and 50 years were investigated. Demographic parameters did not differ between the groups; however, mean FSFI scores were significantly lower in the patient group (p < 0.001). Significantly fewer patients in the IBD group used contraception (p = 0.008). No significant differences regarding conception rates and infertility rates were noted between patients with IBD and control participants (p = 0.533 and p = 0.506, respectively). Conclusions: Female sexuality is significantly impaired in patients with IBD. Women with IBD do not receive sufficient information regarding contraception and should be screened for sexual dysfunction to optimize their quality of life.

Contraception, fertility and inflammatory bowel disease (IBD): a survey of the perspectives of patients, gastroenterologists and women's healthcare providers

OBJECTIVE

Despite guidelines indicating no contraindications for contraceptives in women with inflammatory bowel disease (IBD), this population shows increased voluntary childlessness and lower contraceptive use. Knowledge gaps among healthcare providers on IBD's impact on fertility and contraception may drive these trends. This survey assessed knowledge discrepancies among IBD patients, gastroenterologists (GEs), and women's healthcare providers (WHPs) regarding fertility and contraception.

METHODS

An anonymous survey was conducted between August and December 2023, targeting IBD patients of childbearing age, GEs and WHPs. The questionnaire was offered consecutively to all patients consulting or hospitalised in our department. Additionally, the survey link was shared with healthcare professionals during dedicated training sessions. It assessed awareness of IBD-related fertility and contraception impacts.

RESULTS

Two hundred twenty-two participants fulfilled the survey (100 patients, 50 GEs and 72 WHPs). Among patients (63% with Crohn's disease), 95% were on biologic or immunosuppressant therapy. Nearly half (47%) of women had not discussed fertility or contraception with their GE, and only 22% had done so on request. A majority (80% of women, 54% of GEs) were unsure if IBD affects contraception efficacy, and 50% of WHPs believed oral contraceptives to be less effective for IBD patients. Key concerns influencing patients' fertility decisions included the impact of IBD medication on pregnancy (51%), risk of passing IBD to offspring (47%) and potential flare-ups during pregnancy (39%).

CONCLUSION

Significant knowledge gaps on fertility and contraception in IBD persist among patients, GEs and WHPs.

Perspectives on Contraception, Pregnancy, and Reproductive Health Counseling from Young Women With Inflammatory Bowel Disease

Background/Aims

Active inflammatory bowel disease (IBD) increases the risk of pregnancy complications and contraceptive side effects, and contraceptive use may impact the clinical course of IBD. Although young people are at elevated risk for unintended pregnancy, those with IBD receive minimal disease-specific contraceptive guidance. We characterized perspectives and preferences on contraception and reproductive health counseling from young cis-women with IBD.

Methods

We conducted 60-min semi-structured interviews with cis-women with IBD ages 18-30 (recruited nationwide and from North Carolina IBD clinics; February-June 2023). Interview guides included questions about reproductive health and preferences for receiving reproductive health information. Audio-recordings were professionally transcribed and coded using an inductive, thematic approach and Dedoose software.

Results

Participants included 30 cis-women with IBD (ages 18-30, 77% White, 7% Hispanic, and 55% Crohn's disease). Some participants shared that IBD increased their menstrual symptom burden, prompting contraceptive use to control menses. Participants discussed the impact of IBD on their contraceptive decision-making, including concerns regarding blood clots. For a participant subset, IBD did not impact contraceptive decision-making. Participants discussed how IBD impacted their perspectives on childbearing, including concerns about IBD heritability, infertility, and peripartum IBD flares. Participants wanted their gastroenterology provider to proactively address reproductive health, provide appropriate resources, and coordinate care with reproductive health providers.

Conclusions

Young cis-women with IBD may have IBD-specific concerns about contraceptives, pregnancy, and menstrual symptoms and desire better IBD-related reproductive health counseling. Inflammatory bowel disease providers can improve reproductive health counseling by proactively addressing IBD-specific reproductive health questions, providing reproductive health resources, and coordinating care.

Family Planning for Patients With Inflammatory Bowel Disease in the Post-Dobbs Era

Federal protections for abortion care in the United States ended in June 2022. For people with inflammatory bowel disease (IBD) who are capable of pregnancy, the implications of an unwanted or mistimed conception, particularly in the setting of active disease flares or teratogenic treatment, are precarious and geographically variable. Prioritizing evidence-based and person-centered counseling for preconception health and contraceptive care needs is important during health care visits and not limited to reproductive health providers. Development of multidisciplinary clinics or complex contraception clinics in high-volume IBD centers can support time-sensitive counseling and services for patients. This article reviews reproductive considerations for people with IBD, particularly in the setting of legislative restrictions in the post-Dobbs landscape.

Patients Report Infrequent Counseling by Physicians and Inadequate Knowledge about Inflammatory Bowel Disease and Reproductive Health Issues

OBJECTIVE

Inflammatory bowel disease (IBD) reproductive health counseling is associated with higher knowledge, lower voluntary childlessness, greater medication adherence during pregnancy, and improved outcomes of pregnancy. Our aims were to assess counseling and knowledge about IBD and reproductive health in a tertiary care IBD patient population.

STUDY DESIGN

We anonymously surveyed women and men ages 18 to 45 cared for at the Stanford IBD clinic about reproductive health and administered the CCPKnow questionnaire. STATA was used to summarize descriptive statistics and compare categorical variables using Fisher's exact test.

RESULTS

Of the 100 patients (54% women) who completed the survey, only 33% reported prior reproductive health counseling. Both men and women considered not having a child due to IBD (31% women, 15% men) and most (83%) had no prior counseling. A minority of patients had an adequate (≥8/17) CCPKnow score (45% women, 17% men). The majority of women with prior pregnancy had pre-existing IBD (67%), yet many did not seek gastrointestinal (GI) care (38% preconception, 25% during pregnancy) and 33% stopped/changed medications, with 40% not discussing this with a physician. Prior counseling was significantly associated with education level (p = 0.013), biologic use (p = 0.003), and an adequate CCPKnow score (p = 0.01). Overall, 67% of people wanted more information on IBD and reproductive health.

CONCLUSION

In an educated tertiary care cohort, the majority of patients had low CCPKnow scores and rates of IBD reproductive health counseling. Many patients with IBD prior to pregnancy reported no GI care preconception or during pregnancy and stopped/changed medications without consulting a physician. There is an urgent need for proactive counseling by gastroenterologists and obstetricians on IBD and reproductive health.

KEY POINTS

· There is inadequate reproductive health counseling in IBD.. · Many IBD patients do not seek prenatal/perinatal GI care.. · Patients change medications without consultation.. · GIs and OBs should proactively counsel IBD patients..

Managing Pregnancy and Nursing Affecting African American Women with Inflammatory Bowel Disease: Clinical Outcomes and Parenthood

Inflammatory bowel disease (IBD) is a term for two autoimmune diseases encompassing Crohn's disease (CD) and ulcerative colitis (UC) which are lifelong diseases affecting more than 3 million adults (1.3%) in the United States. IBD is characterized by chronic inflammation of the whole digestive system which results in damage to the gastrointestinal (GI) tract. IBD often emerges during adolescence and young adulthood. Maternal morbidity includes physical and psychological conditions that result from or are aggravated by pregnancy and have an adverse effect on a woman's health, the baby's health or both. Some women have health challenges that arise before or during pregnancy that could lead to complications. It is recommended for women to receive health care counseling before and during pregnancy. Compared to other developed countries, the United States has the highest rate of women dying of pregnancy related complications. During the past 25 years maternal mortality has been getting worse. African American women (AAW) with and/or without IBD are dying at significantly higher rates than other groups. This is linked to several factors, i.e., systemic, institutionalized, and structural racism in health-care delivery and subsequent toxic stress from people's lived experiences of racism, limited knowledge about healthcare system function, lack of access to healthcare, (inclusiveness and insurance policies) all of which negatively impact these patients. African Americans (AAs) are also up to three times as likely to experience severe maternal morbidity: unexpected outcomes of labor and delivery, deficient or lacking prenatal care and social determinants of health like lack of transportation, adequate employment, limited literacy, and limited healthcare access contribute to poor health outcomes. Studies on IBD patients indicate Medicaid expansion is associated with reduced rates of maternal morbidity, particularly for African American Women (AAW) and increased access to preconception and prenatal services that make pregnancy and childbirth safer for parent and baby. Herein we examine the physiological changes of pregnancy in patients diagnosed with inflammatory bowel disease and their relationship perinatal outcomes and parenthood.

Patterns of contraceptive use among young Australian women with chronic disease: findings from a prospective cohort study

BACKGROUND

Given chronic disease is increasing among young women and unintended pregnancies among these women are associated with poor maternal and fetal outcomes, these women would benefit from effective preconception care. However, there is a lack of understanding of how these women use or don't use contraception to inform such interventions. This study examined patterns of contraceptive use among an Australian cohort of young women and investigated the influence of chronic disease on contraceptive use over time.

METHODS

Using data from 15,244 young women from the Australian Longitudinal Study on Women's Health (born 1989-1995), latent transition analysis was performed to identify distinct contraceptive patterns among women who were at risk of an unintended pregnancy. Multinomial mixed-effect models were used to evaluate the relationship between contraceptive combinations and chronic disease.

RESULTS

Contraceptive use for women with cardiac and autoinflammatory diseases differed to women without chronic disease over the observation period. Compared to women without chronic disease using the pill, women with cardiac disease had double the odds of using 'other' contraception and condoms (OR = 2.20, 95% CI 1.34, 3.59) and a modest increase in the odds of using the combined oral contraceptive pill and condoms (OR = 1.39, 95% CI 1.03, 1.89). Compared to women without chronic disease who used the pill, women with autoinflammatory disease had increased odds of using LARC and condoms (OR = 1.58, 95% CI 1.04, 2.41), using 'other' contraception and condoms (OR = 1.69, 95% CI 1.11, 2.57), and using the combined oral contraceptive pill and condoms (OR = 1.38, 95% CI 1.09, 1.75). No differences in contraceptive patterns over the observation period were found for women with asthma or diabetes when compared to women without chronic disease.

CONCLUSION

The findings identified a need for effective contraceptive counselling as part of routine chronic disease care and improved communication between health care providers and women with chronic disease to improve young women's contraceptive knowledge and agency in contraceptive choice, particularly for those with cardiac or autoinflammatory conditions. This may be the key to reducing high-risk unintended pregnancies among this vulnerable population.

Determining the impact of the Zika pandemic on primary care providers' contraceptive counseling of non-pregnant patients in the US: a mixed methods study

BACKGROUND

Global pandemics like Zika (ZIKV) factor into pregnancy planning and avoidance, yet little is known about how primary care providers (PCPs) incorporate public health guidance into contraceptive counseling. Study objectives include: 1) determining the impact of the ZIKV pandemic on contraceptive counseling changes; and 2) assessing PCP knowledge and practice regarding contraception, ZIKV, and CDC ZIKV guidelines.

METHODS

Study components included: (1) a retrospective review of electronic health records of non-pregnant, reproductive age women presenting for preventive health visits between 2014 and 2017 assessed using interrupted time series analyses (ITSA) to identify changes in documentation of ZIKV risk assessment and contraceptive counseling; and (2) a sequential, cross-sectional study with quantitative surveys and qualitative, semi-structured interviews of PCPs providing preventive care to non-pregnant patients at eight federally qualified health centers in Utah. We performed descriptive analyses on survey data and analyzed qualitative data for dominant themes using a modified Health Belief Model.

RESULTS

We conducted 6634 chart reviews yielding 9840 visits. The ITSA did not reveal changes in ZIKV risk assessment or contraceptive counseling. Twenty-two out of 40 (55%) eligible providers participated in the provider component. Participants averaged 69 and 81% correct on contraceptive and ZIKV knowledge questions, respectively. Sixty-five percent reported counseling consistent with CDC ZIKV guidelines. Qualitative analysis found providers unlikely to prioritize ZIKV risk assessment in contraceptive counseling for non-pregnant patients.

CONCLUSIONS

PCPs who care for non-pregnant women are knowledgeable about contraception and ZIKV; however, there was no change in ZIKV risk assessment or contraceptive counseling. This stresses the importance of developing strategies to improve guideline uptake.

Preconception Care Program for Women with Inflammatory Bowel Disease Using Intervention Mapping: A Protocol for Program Development

The prevalence of inflammatory bowel disease in Korea is rapidly increasing. Women with inflammatory bowel disease have a higher risk of adverse birth outcomes than healthy women, and the magnitude of this risk is related to the severity of the disease at the time of pregnancy. For a woman with inflammatory bowel disease to have a healthy pregnancy, interventions are needed to manage the disease before pregnancy—implying a need for pregnancy planning. In this study, the intervention mapping protocol was used to develop a program for this purpose. This protocol contains the following stages: needs assessment, setting of program outcomes and performance objectives, selection of methods and strategies based on theory, and development of the program and its materials. Through individual in-depth interviews and a literature review, individual and environmental determinants were assessed and six change objectives of the program were set. The methods and practical strategies were developed based on the information-motivation-behavioral skills model, self-efficacy theory, and social support theory. The final program, consisting of four sessions and the corresponding materials, was completed by making revisions based on a content validity assessment by experts and a pilot test. Follow-up studies on the implementation of this program will be conducted in the future.

Contraception decision-making and care among reproductive-aged women with autoimmune diseases

OBJECTIVE

In this qualitative study, we sought to understand better the contraception-related experiences and decision-making of women with autoimmune diseases, a group at high risk for adverse pregnancy and perinatal outcomes.

STUDY DESIGN

We conducted semi-structured telephone interviews with women ages 18 to 45 who had at least one autoimmune disease diagnosis. Our team recruited from outpatient rheumatology clinics in Pittsburgh, Pennsylvania. We analyzed our data for content and themes, using inductive and deductive techniques and the constant comparison approach.

RESULTS

The 30 women in the sample ranged from 25 to 44 years old; most were white (73%), married (52%), and had at least one child (53%). Four themes emerged from our interviews: (1) Women's decisions to use contraception were strongly influenced by their diseases and perceptions of their health; (2) Women felt that hormonal contraception was unsafe in the context of their diseases, even women without clear disease-related health risks; (3) Health care providers influenced women's consideration and selection of contraceptive methods; (4) Women rarely expected that their rheumatologists would prescribe their contraception, yet their contraception prescribers lacked knowledge about their disease-specific health risks.

CONCLUSIONS

Women perceived that hormonal contraception is unsafe in the context of their autoimmune diseases and cited medication fatigue and safety concerns as reasons why they did not use contraception. Some women did not appear to receive patient-centered contraception counseling from providers. Our interviews reveal areas for improving contraception care, including augmenting shared decision-making and educating patients and providers about contraception safety.

IMPLICATIONS

Our findings highlight potential tensions between patients' preferences for contraception, safety considerations, and ethical and medically responsible contraception care by health care providers in the rheumatology context. Future work is needed to develop person-centered, medically-appropriate models for contraception care that meet the needs of medically vulnerable populations.

Preconception counseling of females with inflammatory bowel disease

Inflammatory bowel diseases (IBD) are commonly diagnosed in women of childbearing age. As such, pregnancy is often encountered in this subset of patients. Management of pregnancy in IBD patients poses numerous challenges as ensuring the safety of the mother and the fetus is required. Disease remission prior to pregnancy is a key determinant of both the course of IBD throughout gestation and pregnancy outcome. Thus, adequate preconception care is of paramount importance in order to achieve optimal maternal and perinatal outcomes and maintain disease quiescence throughout gestation. In addition, preconception care has a major role in improving patient's knowledge, concerns and misbeliefs related to reproductive-health issues among IBD patients. In this review, we discuss the various aspects involved in the preconception care of IBD patients.

Anti-TNF Therapy in Pregnant Women With Inflammatory Bowel Disease: Effects of Therapeutic Strategies on Disease Behavior and Birth Outcomes

BACKGROUND

Active inflammatory bowel disease (IBD) adversely affects pregnancy outcomes. Little is known about the risk of relapse after stopping anti-tumor necrosis factor (anti-TNF) treatment during pregnancy. We assessed the risk of relapse before delivery in women who discontinued anti-TNF treatment before gestational week (GW) 30, predictors of reduced infant birth weight, a marker associated with long-term adverse outcomes, and rates and satisfaction with counseling.

METHODS

Pregnant women with IBD receiving anti-TNF treatment were prospectively invited to participate in an electronic questionnaire carried out in 22 hospitals in Denmark, Australia, and New Zealand from 2011 to 2015. Risk estimates were calculated, and birth weight was investigated using t tests and linear regression.

RESULTS

Of 175 women invited, 153 (87%) responded. In women in remission, the relapse rate did not differ significantly between those who discontinued anti-TNF before GW 30 (1/46, 2%) compared with those who continued treatment (8/74, 11%; relative risk, 0.20; 95% confidence interval [CI], 0.02 to 1.56; P = 0.08). Relapse (P = 0.001) and continuation of anti-TNF therapy after GW 30 (P = 0.007) were independently associated with reduced mean birth weight by 367 g (95% CI, 145 to 589 g; relapse) and 274 g (95% CI, 77 to 471 g; anti-TNF exposure after GW 30). Of 134 (88%) women who received counseling, 116 (87%) were satisfied with the information provided.

CONCLUSIONS

To minimize fetal exposure in women in remission, discontinuation of anti-TNF before GW 30 seems safe. Relapse and continuation of anti-TNF therapy after GW 30 were each independently associated with lower birth weight, although without an increased risk for birth weight <2500 g. Most women received and were satisfied with counseling.

Pregnancy and multiple sclerosis: Risk of unplanned pregnancy and drug exposure in utero

Background

Multiple sclerosis is a central nervous system demyelinating disease that affects women of reproductive potential. It is important to identify the frequency and risk factors of unplanned or disease-modifying therapy-exposed pregnancies to create interventions to reduce these.

Methods

This retrospective, single-center, observational chart review study aims to identify risk factors for unplanned pregnancy to identify a target population for family counseling.

Results

In total, 63 live births in 45 patients (20 unplanned and 43 planned) were analyzed. The percentage of unplanned pregnancy was 32%. The proportion of those receiving family planning counseling was lower in the patients with unplanned pregnancies (p < 0.001). The main risk factors for unplanned pregnancy were younger age (p = 0.004), disease-modifying therapy exposure (p < 0.001), and being unmarried (p < 0.001). Overall, 16 pregnancies had disease-modifying therapy exposure and in a subsequent study the risk for disease-modifying therapy exposure was unplanned status (p < 0.001). Birth outcomes were not different between groups. There were more enhancing lesions in the post-partum magnetic resonance imaging of women with planned pregnancy (p < 0.04).

Conclusion

Prevention of unplanned pregnancy could lead to less disease-modifying therapy exposed pregnancies. This study suggests a targeted intervention of family planning counseling in younger, unmarried multiple sclerosis patients could potentially lead to less unintended in utero disease-modifying therapy exposure.

Contraception, Venous Thromboembolism, and Inflammatory Bowel Disease: What Clinicians (and Patients) Should Know

The peak incidence of the inflammatory bowel diseases (IBDs) is between the second and fourth decades of life, which coincides with prime reproductive years. Unplanned or mistimed pregnancies may account for nearly half of all pregnancies and are associated with adverse consequences such as a higher risk of delayed preconceptual care, increased risk of preterm birth, low birth weight, and adverse maternal and neonatal outcomes. Increased IBD activity during pregnancy is also associated with adverse pregnancy-related outcomes, such as miscarriage, intrauterine growth retardation, and preterm birth. Furthermore, the increased risk of venous thromboembolism (VTE) conferred by active IBD may be potentially augmented by hormonal contraceptives. Recent literature suggests that women with IBD seek counseling on contraception from gastroenterologists in preference to their primary care physicians. Meanwhile, attitudes and awareness regarding contraception counseling remain suboptimal, underpinning the importance and need for physician and patient education in this area. We discuss the association between contraception and IBD, benefits and risks associated with various contraceptive methods in women with IBD, and practical recommendations for clinicians caring for women with IBD. 10.1093/ibd/izz025_video1 izz025.video1 6014727518001 10.1093/ibd/izz025_video2 izz025.video2 6014726992001.

Deficiencies in reproductive health counseling in liver transplant recipients

BACKGROUND

In liver transplant (LT) recipients of childbearing age, there is often rapid return of fertility post-transplant. Our aim was to determine whether healthcare providers are documenting reproductive health counseling in LT recipients.

METHODS

We performed a review of 365 LT recipients (164 female, 201 male) of childbearing age transplanted between 1994 and 2015 at a single center. We evaluated documentation of reproductive health counseling, content of the counseling and its provider.

RESULTS

Reproductive health counseling was documented in 7% of LT recipients (14% of females, 0.5% of males). The transplant team provided the counseling in 56%, obstetrics/gynecology in 35%, and primary care in 9%. Twenty-four post-LT pregnancies occurred; these were unplanned in 13%. Miscarriage/stillbirth occurred in 7/24 pregnancies (29%). Mycophenolic acid was used by 20% of female recipients at conception. Only age at transplant (P = 0.001) and post-LT pregnancy was associated with documentation of reproductive health counseling in female recipients (P = 0.0001).

CONCLUSION

Despite rapid return of fertility in reproductive-aged LT recipients, documentation of reproductive health counseling in this population is rare in men and women. This increases the potential for adverse maternal and fetal outcomes in this high-risk population.

Systematic review: the consequences of psychosocial effects of inflammatory bowel disease on patients' reproductive health

BACKGROUND

High levels of voluntary childlessness and pregnancy-related fears have been reported amongst inflammatory bowel disease (IBD) patients.

AIMS

To investigate what factors determine IBD patients' childbearing decisions; and to examine psychosocial consequences of IBD on various aspects of patients' reproductive health.

METHODS

Six electronic databases were searched in a pre-specified and structured manner.

RESULTS

A total of 41 articles with data on 7122 patients were included. Between one-fifth to one-third of IBD patients had chosen voluntary childlessness. Around 50% of all IBD patients have poor knowledge of pregnancy-related issues in IBD. Poor knowledge of pregnancy-related issues in IBD was associated with voluntary childlessness. Observational studies have found preconception counselling is associated with patients choosing parenthood. Pregnancy-related fears and concerns are multifaceted, stemming partly from lack of knowledge of pregnancy-related issues in IBD. Many female patients are considered at increased risk for pregnancy because between one-fifth to one-third of patients do not use contraception. Research evidence for sexual dysfunction after disease diagnosis and treatment is inconsistent. There are limited data on patients' pregnancy, postpartum and parenting experiences. A few shortcomings of the literature are evident; sample sizes were small, participation rates were low, use of non-validated questionnaires was common, and few studies included men and/or ethnic minority groups. The design of intervention studies is also weak.

CONCLUSION

This review recommends pre-conception counselling for all IBD patients of childbearing age to tackle poor knowledge and allow patients to make an informed decision on their reproductive health.

Family planning in inflammatory bowel disease: childlessness and disease-related concerns among female patients

OBJECTIVE

Inflammatory bowel disease (IBD) frequently affects women when family planning and pregnancy (FPP) are important issues. This survey aimed to identify patients with an increased need for medical counselling.

PATIENTS AND METHODS

An internet-based questionnaire was offered to women with IBD. Characteristics in terms of FPP were analysed with respect to sociodemographic and disease-related factors.

RESULTS

Childlessness was frequently reported (64.8% of 443 participants). In women older than 35 years with IBD, childlessness was significantly more prevalent than that in the general population (36.7 vs. 22.9%, odds ratio=1.9, P<0.001). Overall, 44.2% of the women were satisfied with counselling in general, and only 27.3% with the specific advice on FPP. Women younger than 25 years were rarely satisfied with the advice in terms of FPP (18.2%) and demanded an intensified counselling (44.6%). Frequent concerns were the heritability of IBD (all women, 59.2%; mothers, 51.5%; childless, 62.5%, P<0.01), medication during FPP (44.7, 26.1, 52.4%, P<0.01) and miscarriage (38.9, 16.8, 48.7%, P<0.01).

CONCLUSION

The prevalence of childlessness in women with IBD compared with the general population increases with age. FPP-related worries, especially in terms of heredity, medication and miscarriage, are associated with an increased risk for childlessness. The results underline the importance of qualified counselling as early as possible during the course of the disase.

Contraceptive Considerations for Women with Gastrointestinal Disorders

Gastroenterologists are in a unique position to assist women with chronic gastrointestinal disorders in order to optimize their health prior to pregnancy. Women, whether with chronic conditions or not, and their infants are more likely to be healthy when pregnancies are planned. Achieving a planned pregnancy at the ideal time or preventing pregnancy altogether requires the use of appropriate contraceptives. There is a broad range of contraceptives available to women in the USA, and the majority of women with digestive diseases will be candidates for all effective methods. Guidance from the Centers for Disease Control and Prevention aids clinicians in prescribing appropriate contraceptives to women with medical disorders. This review will focus on contraception for women with inflammatory bowel disease and chronic liver disease, including liver transplant.

Management of Inflammatory Bowel Disease During Pregnancy

Inflammatory bowel disease (IBD) usually affects women during their reproductive years and many concerns arise among these young patients. Pre-pregnancy consultation with a multi-disciplinary team is very important. The team should make patients aware of the critical importance of ensuring that conception occurs during a period of disease remission. Conception during an IBD flare-up results in disease activity or even exacerbates disease in two-thirds of women. Exacerbation of the disease is associated with increased frequency of maternal and fetal complications. Drug therapy constitutes a considerable source of patient anxiety but most drugs used for treating IBD are considered safe. Therefore, continuing pharmacological therapy during pregnancy is necessary to maintain disease control. Optimization of pre-conception nutritional status and smoking cessation are also emphasized. The general guideline for most patients, except for active perianal disease patients, is to aim for vaginal delivery in the absence of obstetric contraindications. Consistent, ongoing follow-up, as detailed in this review, should allay the anxieties and fears surrounding continuing immunosuppressive drugs during pregnancy, allowing each patient to attain the optimal conditions for achieving her goal of holding a healthy baby.

Hormonal Contraception Use is Common Among Patients with Inflammatory Bowel Diseases and an Elevated Risk of Deep Vein Thrombosis

BACKGROUND

Persons with inflammatory bowel disease (IBD) have an increased risk of venous thromboembolism. We sought to examine whether the self-report of hormonal contraception (HC), as a proxy for exposure to estrogen-based contraception, was less common for women with multiple risk factors for venous thromboembolism.

METHODS

We examined the prevalence of personal use of hormonal birth control in a large internet-based cohort of patients with IBD. To determine whether HC was less common among patients with IBD with increased risk of thrombosis, we estimated unadjusted and adjusted prevalence ratios (PRs) for the use of HC.

RESULTS

Thousand four hundred ninety-nine female survey respondents answered optional fertility questions and were included in the analysis. The prevalence of HC was 33.7% (95% CI, 30.6%-36.9%) among women with Crohn's disease and was 32.6% (95% CI, 28.6%-36.8%) for women with ulcerative colitis. Women with one risk factor for thrombosis were not significantly less likely to receive HC (PR = 0.91, 95% CI: 0.76-1.08; adjusted PR = 0.94, 95% CI: 0.80-1.11) compared with women without risk factors nor were women with 2 or more risk factors (PR = 1.10, 95% CI 0.56-1.28; adjusted PR = 1.10, 95% CI: 0.83-1.45). The use of an intrauterine device was also similar between women with and without risk factors for venous thromboembolism.

CONCLUSIONS

The prevalence of HC use in women with multiple risk factors was similar to that in women without risk factors, which represents an opportunity for prevention. Gastroenterologists should ask patients with IBD using HC about risk factors for thromboembolic disease to identify patients who may benefit from alternative contraception.

Integrating Adolescents and Young Adults into Adult-Centered Care for IBD

Planned healthcare transition, initiated in pediatric care, is a gradual process aimed at fostering the adolescent patient's disease knowledge and skills with the ultimate objective of preparing patients and families for adult-centered care. The process is critical in inflammatory bowel diseases (IBD) where there is an increased risk of non-adherence, hospitalizations, and emergency department use as young adult patients graduate from pediatric to adult-centered care. While evidence for healthcare transition in IBD is mounting, important gaps remain in the understanding of this process from the perspective of the adult gastroenterologist. This paper summarizes what is known about healthcare transition in IBD and explores the unanswered questions-a conceptual and methodological framework for transition interventions, relevant outcomes that define successful transition, and key stakeholder perspectives. For the adult gastroenterologist managing the young adult patient population, this paper presents the paradigm of "care integration"-a process of ongoing, multi-modality support for the patient, initiated in the adult care setting, with the goal of improving self-management skills and active participation in medical decision-making.

Reproductive Planning and Contraception for Women with Inflammatory Bowel Diseases

Women with chronic medical conditions, such as inflammatory bowel diseases, are at increased risk for adverse pregnancy outcomes. Pregnancy outcomes for these conditions are best during stable disease remission. Unfortunately, women with inflammatory bowel disease are equally as likely as the general population to have unintended pregnancies. Patients look to their gastroenterologist for contraceptive counseling; however, the current standards for disease management do not prioritize this topic. Guidelines based on available evidence and expert opinion, such as the Centers for Disease Control U.S. Medical Eligibility Criteria for Contraceptive Use, exist to help practitioners provide safe and effective contraception to women with chronic medical conditions. If health care providers were to educate themselves and screen women with inflammatory bowel disease for risk of unintended pregnancy, there would be a reduction in the number of unintended pregnancies and subsequent adverse neonatal and maternal outcomes.

Fertility and Contraception in Women With Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) carries a high burden in women during their reproductive years, and family planning issues are often a significant cause of concern. Fertility is normal in women with nonsurgically treated ulcerative colitis and similar or slightly reduced in women with Crohn's disease. Women who undergo ileal pouch anastomosis have reduced fertility. Fertility is likely worsened by disease activity but unaffected by medications used to treat IBD. Infertile patients with IBD respond as well as non-IBD patients to in vitro fertilization (IVF). Despite normal fertility, patients with IBD have fewer children due to concerns regarding infertility, disease inheritance, congenital abnormalities, and disease-related sexual dysfunction. Patients rarely discuss these issues with a physician. When discussion does occur, it may lead to changes in decision-making. Contraceptives are an important part of family planning, particularly during times of high disease activity. All forms of contraceptives are acceptable in patients with IBD, although there are specific considerations. The risks of combined oral contraceptives outweigh the benefits in patients with active disease and patients with prior or high risk for thromboembolism. Oral contraceptives and IBD are independently associated with an increased risk for thromboembolism, although it is not known whether this effect is compounding. Depot medroxyprogesterone acetate injection should be avoided in patients with or at risk for osteopenia. Intrauterine devices and implants are the most effective form of contraception and should be a first-line recommendation. The use of oral contraceptives is associated with the development of IBD, although there is no increased risk of disease relapse with the use of any form of contraceptive.

Use of Immunomodulators and Biologics Before, During, and After Pregnancy

Immunomodulators and biologic medications, alone or in combination, form the core therapeutic strategy for managing moderate-to-severe inflammatory bowel disease (IBD). IBD incidence peaks during the prime reproductive years, raising concerns about the impact of disease and its treatment on fertility, maternal and fetal health during pregnancy, breastfeeding safety, and childhood development. Although IBD increases risk of pregnancy complications independent of disease activity, adverse pregnancy outcomes are more common when disease is active. To mitigate fetal risk, women should conceive while disease is quiescent. Aside from methotrexate, immunomodulators and biologics may be used during pregnancy to achieve and maintain disease control. Based on available safety data, there is no increased risk of congenital anomalies among infants exposed to these medications. Active thiopurine metabolites and most monoclonal antibodies cross the placenta and are detectable in neonates. They are detectable in breast milk in minute levels as well. The impact of this exposure on neonatal outcomes is discussed. Adjusted dosing schedules during gestation may reduce fetal drug exposure, though the maternal risks of such manipulation require careful consideration. Ongoing prospective studies will further inform risk assessment, including for newer medications such as the anti-integrin agents.

Sex-Specific Issues in Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) affects approximately 1 in 500 people living in the United States and generally occurs with equal frequency in men and women. However, despite equal sex distribution of the disease, men and women face unique challenges that can significantly impact quality of life. As more is discovered regarding the pathogenesis, clinical manifestations, and treatment of IBD, physiologic and psychological differences between men and women with IBD have become increasingly apparent. It is important to understand these differences, as they have the potential to affect patient care and outcomes. This article will review sex-specific issues in IBD, such as impaired body image and sexuality, increased risk of cervical cancer, altered menstrual cycles, reduced fertility, and low bone mineral density.

The Emerging Adult with Inflammatory Bowel Disease: Challenges and Recommendations for the Adult Gastroenterologist

Incidence of pediatric inflammatory bowel disease (IBD) is rising. Adult gastroenterologists are seeing increasing numbers of young adults with IBD, a subpopulation with unique needs and challenges that can impair their readiness to thrive in an adult healthcare system. Most adult gastroenterologists might not have the training or resources to address these needs. “Emerging adulthood” is a useful developmental lens through which this group can be studied. With complex disease phenotype and specific concerns of medication side effects and reproductive health, compounded by challenges of geographical and social flux and lack of adequate health insurance, emerging adults with IBD (EAI) are at risk of disrupted care with lack of continuity. Lessons learned from structured healthcare transition process from pediatric to adult services can be applied towards challenges in ongoing care of this population in the adult healthcare system. This paper provides an overview of the challenges in caring for the post transition EAI from the perspective of adult gastroenterologists and offers a checklist of provider and patient skills that enable effective care. This paper discusses the system-based challenges in care provision and search for meaningful patient-oriented outcomes and presents a conceptual model of determinants of continuity of care in this unique population.

Does the level of reproductive knowledge specific to inflammatory bowel disease predict childlessness among women with inflammatory bowel disease?

BACKGROUND

Women with inflammatory bowel disease (IBD) may choose to remain childless due to a lack of IBD-specific reproductive knowledge.

OBJECTIVES

To examine the effects of IBD-specific reproductive knowledge and discussion of family planning with a physician on childlessness among women with IBD.

METHODS

Female IBD patients 18 to 45 years of age completed the Crohn's and Colitis Pregnancy Knowledge questionnaire (CCPKnow), and answered questions regarding reproductive history, plans to have children and discussion of family planning with a physician. CCPKnow scores were grouped according to poor (0 to 7), adequate (8 to 10), good (11 to 13) and very good (14 to 17).

RESULTS

Of 434 eligible women, 248 (57.1%) completed the questionnaires. Of these 248 women, 51.6% were childless and, among these, 12.9% were voluntarily childless and 12.1% were trying to become pregnant. Childless women had a lower median CCPKnow score than women with children (6.0 versus 8.0; P=0.001). After adjusting for current age and marital status, each one point increase in the CCPKnow score corresponded to 8% lower odds of childlessness (OR 0.92 [95% CI 0.86 to 0.99]), 9% lower odds of voluntary childlessness (OR 0.91 [95% CI 0.79 to 1.0]) and 20% higher odds of trying to become pregnant (OR 1.2 [95% CI 1.0 to 1.4]). Discussion of family planning with a gastroenterologist corresponded to 72% lower odds of a poor CCPKnow score (OR 0.28 [95% CI 0.15 to 0.53]) and of voluntary childlessness (OR 0.28 [95% CI 0.057 to 1.3]).

CONCLUSION

In the present study, higher IBD-specific reproductive knowledge lowered the odds of childlessness among women with IBD. Discussion of family planning with a physician was associated with higher CCPKnow scores and lower odds of voluntary childlessness.

The use of biologic therapy in pregnancy: a gastroenterologist's perspective

PURPOSE OF REVIEW

Inflammatory bowel disease (IBD) often affects women in their peak reproductive years, and therapy is often continued during pregnancy to maintain stable disease activity. Therapeutic options have expanded over the last 2 decades with the advent of new biologic options. It is, therefore, important for the gastroenterologists and other clinicians caring for patients with IBD to understand safety data regarding the treatment options, both biologic and nonbiologic, in pregnant IBD patients.

RECENT FINDINGS

In general, quality of evidence in this area remains low. However, larger prospective studies are beginning to provide evidence regarding the potential safety of biologics both alone and in conjunction with nonbiologic therapy.

SUMMARY

The majority of treatment options for IBD appears to be of low risk and may often be continued through pregnancy and lactation. Not treating IBD, for example, by discontinuing therapy prior to or with pregnancy, may pose a greater risk to mother and fetus in many cases.

Contraceptive method selection by women with inflammatory bowel diseases: a cross-sectional survey

OBJECTIVE

Women with inflammatory bowel diseases (IBDs) utilize contraception at a lower rate than the general population. We sought to identify factors associated with contraceptive use and selection of more effective methods in IBD patients at risk for unintended pregnancy.

STUDY DESIGN

An online survey was distributed to women with IBD in January 2013. Contraceptive methods were categorized by effectiveness and associations with use explored by demographics, disease characteristics and reproductive goals.

RESULTS

A total of 162 respondents were analyzed: 62% had Crohn's disease and 38% ulcerative colitis. Mean age was 31 (range 20-45), 97% identified as White, and 53% were nulliparas. Seventy-four percent were currently using IBD medications. A quarter of participants (23%) used no contraception, 17% used highly effective methods, 41% used short-term hormonal methods, and 19% chose barrier/behavioral methods. Prior IBD-related surgery, biologic therapy use and low education attainment were associated with no contraception use. Of contraceptive users, age, parity, insurance status, IBD surgery and prior immunomodulator use were associated with highly effective method selection.

CONCLUSIONS

A quarter of women with IBD at risk for pregnancy in this study population reported no contraceptive method use. Higher levels of IBD activity influence contraceptive use and method selection, which could guide future patient and provider educational interventions.

IMPLICATIONS

Pregnancy planning is important for women with inflammatory bowel diseases to avoid adverse outcomes in a disease-poor state. Use of contraception assists in avoidance of unintended pregnancy. IBD characteristics are targets for educational interventions to improve uptake of highly effective contraceptive methods.