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

Motherhood and pregnancy concerns of Saudi females with multiple sclerosis in Riyadh city: A quantitative analysis

OBJECTIVES

To explore the concerns among females in Riyadh city with multiple sclerosis (MS) regarding motherhood and pregnancy outcomes.

METHODS

In this cross-sectional study, data were collected using an online questionnaire. Women who were aged 18-50 years and diagnosed with MS by a neurologist and had a disease duration of at least one year were included. The questionnaire consisted of 7 sections designed to collect information on the respondents' sociodemographic characteristics; past and current medical history; pre-pregnancy, pregnancy, and postpartum concerns; physical and psychological concerns about parenthood; and psychological and social support.

RESULTS

A total of 176 women were included in the final analysis. Fatigue was the most common MS symptom, reported by 85.2% of the respondents, and 58% of the respondents had concerns about their disease and medication having adverse effects on their pregnancy and fetal outcomes. We found a statistically significant association between the level of perceived social support and patient care during pregnancy and concerns that they would not be able to prepare food for their children (p=0.037, respectively).

CONCLUSION

We have identified several significant concerns of Saudi women with MS related to various aspects of pregnancy, delivery, and fetal outcomes. These concerns may be linked to a lack of adequate knowledge on the subject. Thus, receiving appropriate counseling, information, and support could greatly benefit these women and result in a more positive and comfortable pregnancy and delivery experience.

Effect of Cladribine Tablets on the Pharmacokinetics of a Combined Oral Contraceptive in Pre-Menopausal Women With Relapsing Multiple Sclerosis

This study assessed the effect of cladribine tablets (CladT) on the pharmacokinetics (PK) of a combined oral contraceptive (COC) in pre-menopausal women with relapsing multiple sclerosis. It was a randomized, double-blind, two-period, two-sequence crossover study to assess steady-state plasma PK (area under the concentration-time curve and peak concentration) of COC (ethinylestradiol [EE] 30 μg and levonorgestrel [LNG] 150 μg) when co-administered with CladT or placebo. Participants received 2 weeks of active CladT treatment per course (Weeks 1 and 5 per year) to have a cumulative dose of 3.5 mg/kg over 2 years as per label. Of the 24 randomized participants, 23 completed the study. The results showed that the concentration-time profiles as well as PK parameters of EE and LNG in the plasma were similar when co-administered with CladT or placebo. Analysis of variance confirmed the bioequivalence of EE and LNG in COC when co-administered with either CladT or placebo. All participants were adequately exposed to cladribine. Repeat-dose administration of CladT had no apparent effect on serum luteinizing hormone, follicle-stimulating hormone, progesterone, or sex hormone-binding globulin concentrations during concomitant treatment with COC. Co-administration with COC did not change the known safety and tolerability profile of CladT and did not alter the PK of EE or LNG in a COC during the study. Therefore, the concomitant use of CladT is not expected to decrease the efficacy of COCs containing EE and LNG. Trial Registration: EudraCT Number: 2018-001015-70.

Patient-centered pregnancy planning in multiple sclerosis: evidence for a new era

A few decades ago, women diagnosed with multiple sclerosis were discouraged from becoming pregnant. However, with new knowledge about the disease and treatments, this recommendation has changed, and it is pregnancy after the diagnosis of the disease is no longer contraindicated, with family planning being essential in this process. This review aims to provide a comprehensive overview of the family planning process for people with multiple sclerosis.

Male sexual and reproductive health in multiple sclerosis: a scoping review

BACKGROUND

Multiple sclerosis (MS) is a chronic neuroinflammatory disease with highest incidence during the period of optimal reproductive health. This scoping review aimed to identify and summarize available data on sexual/reproductive health in males with MS (MwMS).

METHODS

This review was based on PRISMA extension for Scoping Review. PubMed database was searched for keyword "multiple sclerosis" alongside keywords "sexual health", "reproductive health", "family planning", "male fertility", "male infertility", "sexual dysfunction", and "erectile dysfunction", iteratively using the "AND" logical operator. Descriptive analysis was performed on the included articles.

RESULTS

Thirty-four studies were included, and four topics emerged: sexual dysfunction, erectile dysfunction, fertility, and family planning. Sexual dysfunction is common in MwMS (35-72%), yet only a minority of MwMS discuss their sexual health with their treatment teams. Both MS disability and depression were associated with sexual dysfunction in MwMS, with erectile dysfunction and decreased libido as the most prevalent aspects of sexual dysfunction. Positively, phosphodiesterase-5 inhibitors appear effective for treating erectile dysfunction and improving sexual quality of life in MwMS. There may also be a relationship between MS and male infertility, though changes in sexual behavior may underlie this association. Finally, a prominent knowledge gap was observed for disease-modifying therapy use and family planning in MwMS.

CONCLUSION

Sexual dysfunction is common, impacted by MS severity, and associates with decreased quality of life in MwMS. Communication barriers regarding sexual and reproductive health appear to exist between MwMS and providers, as do literature gaps related to MS therapeutics and sexual/reproductive health.

[Pregnancy and breastfeeding in women with multiple sclerosis]

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

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

Background

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

Methods

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

Results

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

Conclusion

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