Family planning and subsequent DMT decisions may help overcome low fertility rate in women with MS

Recent research from Italy, published in Journal of Neurology Neurosurgery and Psychiatry, has highlighted the importance of timely informing women with MS on family planning to fill or, at least, reduce the gap in fertility with the general population. 

Multiple sclerosis (MS) is a potentially disabling disease of the central nervous system, which mostly affects women of childbearing age, and, thus, can potentially impact on fertility, pregnancy and childbirth outcomes. In particular, reduced fertility rates are expected in MS as a consequence of disease-related and treatment-related sexual dysfunction (ie, vaginal dryness, changes in sensation, decreased desire and arousal), and of its psychological impact (eg, concerns about inadequate parenting abilities and passing on MS to a child). Pregnancy and delivery can be complicated in women with more severe MS-related disability by higher risk of miscarriage and C-section. The risk of birth defects can increase with some disease-modifying treatments (DMTs) with unknown or high teratogenic potential. Finally, after a general improvement of MS symptoms during pregnancy, delivery can be followed by rebound relapses and MRI activity.

In this present population-based study, conducted on routinely collected data from 2018 to 2020 in the Campania region of Italy, the researches evaluated fertility, pregnancy and childbirth outcomes in women with MS, when compared with the general population, and in relation to DMTs.

The authors showed substantially stable fertility rates from 2018 to 2020, compared with twofold higher rates in the general population. Moccia et al say that based on their results, the low rate of fertility could be due to a number of actionable factors, including late family planning, when compared with the general population, and concerns over disease control, with low utilisation of DMTs and subsequent risk of relapses.

Women with MS with pregnancy between 2018 and 2020 were older and had lower number of previous pregnancies, when compared with general population, overall suggesting they achieved pregnancy in later stages of life. However, within the MS population, pregnancy and delivery occurred in women with MS of younger age, thus suggesting that family planning should be discussed in the early stages of the disease, to guide DMT decisions and to achieve successful outcomes. Pregnancy duration in MS was lower, confirming previous estimates of 7% higher risk of preterm births in MS, when compared with general population.

The authors found 5 cases of birth defects (3.3% prevalence), which is not far from previous similar studies, and from pooled prevalence of congenital malformations in MS (from 2.7% to 6.1%).  

Before pregnancy (12 months before conception), most women with MS (88.3%) were treated with DMTs. However, at the time of conception, 26.6% of women with MS were either untreated or already discontinued from their DMTs, and additional 50% discontinued from their DMTs after conception, with overall 76.6% of women with MS being untreated during pregnancy. Women with MS with pregnancy were less exposed to DMTs, when compared with women with MS without pregnancy, with subsequently higher risk of relapses. However, women with MS that were treated during pregnancy, most likely continued on the same DMT after delivery (91.7%), suggesting disease stability was achieved.  A number of women with MS might not require DMT during pregnancy, in the case of active MS, safe medications should be considered to achieve disease control during pregnancy, say the authors.

In our study, we found that, after delivery, most women with MS (90%) breastfed, with 70% using breast milk exclusively for 6 months. Most recent Italian population-level data on breastfeeding (2013) showed that up to 85.5% of women breastfeed for average 8.3 months, with increasing rates over the past decades.39 As such, our results are in line with general population estimates, and further confirm good pregnancy outcomes (including breastfeeding) in MS. While the impact of breastfeeding on MS relapses and progression remains unclear,40 41 breastfeeding is definitely important to a woman’s life and, thus, should be encouraged also thanks to breastfeeding-safe DMTs,8 42–44 which, in our study, were associated with increased probability of breastfeeding. Again, we based our safety classification on European agency reports, and have to acknowledge that additional evidence has accumulated over the recent years, but was definitely not available at the time of study conduction (2018–2020).

In conclusion, our research highlighted the importance of timely informing women with MS on family planning to fill or, at least, reduce the gap in fertility with the general population. Timely and up-to-date information on conception, pregnancy, delivery and breastfeeding should be provided to women with MS for fully-informed decision-making process, including preferring or switching to alternate DMTs.  Proper family planning and DMT strategy may ultimately result into better quality of life for women with MS and reduced societal costs.

Reference:

Moccia M, Affinito G, Fumo MG, et al Fertility, pregnancy and childbirth in women with multiple sclerosis: a population-based study from 2018 to 2020 Journal of Neurology, Neurosurgery & Psychiatry 2023;94:689-697.

http://dx.doi.org/10.1136/jnnp-2022-330883