Life with MS

During the 2020 annual meeting of the Consortium of Multiple Sclerosis Centers, there were presentations relating to family planning, pregnancy and lactation (breastfeeding) in persons living with multiple sclerosis. Here is what we learned:

Medication Safety

• If birth control pills are used to prevent pregnancy, they should be stopped and menstrual cycle normalized prior to stopping a disease-modifying therapy and planning for conception.

• None of the current oral therapies are deemed safe for the fetus during pregnancy or the baby during the time of breastfeeding. Fingolimod (Gilenya) and Siponimod (Mayzent) should be stopped at least two months prior to conception. Because rebound relapse rates are high with these drugs, it is recommended to transition to one of the injectable interferons or glatiramer acetate immediately when coming off these oral medications.

• The injectable drugs are safe to use during pregnancy and breastfeeding. It is also thought that every six-month infusions of Ocrelizumab or Rituximab are a reasonable therapy to transition to from these oral medications.

• Pregnancies associated with Natalizumab (Tysabri) are linked to a small increase in the incidence of miscarriage and that drug needs to be stopped by the last trimester of pregnancy. Teriflunomide (Aubagio) has been associated with miscarriages and birth defects in the animal model of MS. This is also true when a man with MS is on this medication and plans to father a child as the drug is found in sperm.

• Cladribine (Mavenclad) taken two months prior to conception gives an additional ten months of protection from increased disease activity so may be a drug to consider when planning to get pregnant. This drug may also be suggested as a full course over a 13-month period prior to planning to conceive as it is thought to incur a long-term protection against relapse so a woman would not need a DMT during pregnancy or lactation if this drug is completed prior to pregnancy.

• It is suggested both oral prednisone and intravenous Solumedrol are safe in the management of a relapse during pregnancy after the first trimester as well as during lactation. Dexamethasone, however, is not a safe steroid for use during these times in a woman’s reproductive life span.

• It is safe to have an MRI, if needed, during pregnancy but gadolinium or a dye to enhance lesions on MRI is not safe to use.

• Modafinil (Provigil) and antibiotics decrease the effectiveness of oral contraceptives so when taking these medications additional birth control measures need to be taken to prevent conception until such time as the couple plans to start a family.

Fertility and Relapse

• Assisted fertilization or IVF has been shown to provoke a higher relapse rate in women with MS who are trying to conceive. This is especially true if the first cycle of this does not result in pregnancy. The more attempts at IVF, the greater the risk of relapse.

• There is no evidence that MS decreases a woman’s fertility but men may show a lower or slower sperm count so, if unable to initially conceive, these factors may need to be addressed.

• Libido or sexual drive may be diminished in both men and women with MS.

• If a woman has a relapse during pregnancy, it seems to be a predictor of more active disease and a higher likelihood of relapse soon after delivery.

• More than 40 percent of women with MS have a relapse four to six months after delivery unless they are exclusively breastfeeding. Exclusive breast feeding means no supplementation with formula or solid food for at least six months. The longer a woman nurses her baby, the greater chance a relapse will be avoided or the time to a first postpartum relapse delayed.

• Relapses during pregnancy are generally less frequent than when not pregnant, especially during the last trimester when hormone levels are at their peak. In fact, most women report they feel best, as far as their MS is concerned, when they are pregnant.

It does not appear that the method of delivery (vaginal or C-section) has any negative effect on the health of mother or baby or on the effect of MS on the mother’s health. Anesthesia is also not contraindicated during labor and delivery.

In short, a couple should start the discussion of family planning, pregnancy, and lactation with members of their healthcare team well in advance of getting pregnant if MS is in the picture. Lifestyle changes that affect pregnancy in women with MS include diet, smoking, level of physical activity, and stress. By addressing these areas prior to conception, the MS can be better managed and pregnancy can be healthier and happier.