IBD & Pregnancy

Inflammatory bowel disease (IBD) frequently affects young people in their reproductive years, and can have a major impact on patients’ family planning decisions. The majority of women with IBD can have healthy pregnancies and healthy babies. One of the most important factors for having a healthy pregnancy is to ensure that your IBD is well controlled both prior to becoming pregnant, as well as throughout your pregnancy. It is important to discuss your plans for starting a family with your IBD doctor and team. The following information sheet will answer some of the most commonly asked questions about pregnancy and IBD.

How does IBD affect Fertility?

Many patients with IBD are concerned about how their disease can affect fertility. An Australian study found that 43% of women with IBD were worried about infertility. Fortunately, women with inactive IBD, both Crohn’s disease (CD) and ulcerative colitis (UC), have fertility rates similar to the general population. However, some women with active IBD, especially CD, can have decreased fertility.

Does surgery have an impact on fertility?

Women with UC who have had their colon removed and had a pouch created (colectomy and ileal pouch‐anal anastomosis (IPAA)) may have reduced fertility. See the pictogram below to see the risk of infertility for the general population, medically treated IBD, and after IPAA. If possible, women who are planning on having children may want to consider alternative surgical procedures, such as colectomy and the formation of an ileostomy, which does not affect fertility, and wait until after child‐ birth to have the pouch surgery. Similarly, women with CD that have had significant surgery in the pelvic region may also have reduced fertility. Women with IBD who are having problems with infertility should ask about a referral to a fertility specialist.

Do IBD medications have an impact on fertility?

To date, IBD medications do not appear to impact fertility in women. Men with IBD may have decreased fertility when taking sulfasalazine. Fertility returns to normal within 3 months of stopping the medications and good alter‐ natives, such as mesalazine, can be taken instead. Methotrexate can affect sperm production and quality, and should be stopped 3‐6 months prior to conception. Methotrexate should also be stopped in women considering pregnancy due to an increased risk of birth defects.

What are the chances of my child having IBD?

Patients with IBD are slightly more likely to have a child with IBD compared to parents without IBD, although the overall risk is still quite low. If one parent has UC, the risk of their child having IBD is 1.6%. If one parent has CD, the risk of their child having IBD is 5.2%. Or, to put this in other terms, less than 2 out of 100 children born to a parent with UC or 5 out of 100 children born to a parent with CD, will get IBD. If both parents have IBD, the risk of their child developing IBD in 36 out of 100, or 36%.

How does pregnancy affect IBD?

The most important factor in predicting how active your IBD will be throughout pregnancy appears to be how active your disease is when you become pregnant. If you conceive during remission, rates of flare are similar to rates for non‐pregnant patients. However, if you become pregnant when your disease is active, your disease is more likely to remain active or get worse.

Interestingly, it appears that pregnancy may have a beneficial effect on the course of IBD, with a lower rate of flares in the years after pregnancy, compared to the years before pregnancy.

What if I have a flare during pregnancy?

Most of the medications used to treat IBD are safe to use in pregnancy, but some are not. It is therefore very important that you discuss your plans to become pregnant with your IBD team, and let them know as soon as possible once you become pregnant. More details on the most common IBD drugs are given in the next section.

If you start to have symptoms of IBD during your pregnancy, let your IBD team know as soon as possible. Investigations may need to be done to determine what is happening. Endoscopic procedures such as flexible sigmoidoscopy and colonoscopy are considered safe in pregnancy, but should only be done if clearly necessary, and in the second trimester if possible. Elective procedures should be delayed until after delivery. MRI and ultrasound are also considered safe, but other radiology tests that involve radiation, such as x‐rays, CT scans, and barium tests, should be avoided.

How does IBD affect pregnancy?

The effect IBD has on pregnancy depends on whether the disease is active or in remission. Current evidence indicates that well controlled disease has minimal impact on the course and outcome of pregnancy. However, it appears that if a woman with active IBD becomes pregnant, or if the disease flares in pregnancy, the risk for adverse outcomes is higher. Several studies have shown that there is an increased risk of preterm delivery and low birth weight babies in women with IBD, particularly in patients who have had active disease either at conception, or throughout their pregnancy. The risk of congenital malformations may be slightly higher in children of mothers with UC, although a number of other studies did not show any increased risk. As active disease is associated with increased risk of adverse outcomes in pregnancy, we therefore recommend, if possible, that women with IBD who are considering becoming pregnant wait until their disease is in remission.

Does IBD influence the route of delivery?

Women with IBD are more likely to have caesarean (C) sections compared to the general population. There are only 2 situations where your gastroenterologist might recommend a C‐section: active perianal disease (inactive peri‐ anal disease does not require a C‐section), and in patients who have a pouch (IPAA). Although the route of delivery was not found to influence whether there were complications with the pouch, the recommendation is based on the theoretical increased risk of incontinence from damage to the anal sphincter with a vaginal delivery.

How do IBD medications affect pregnancy?

The decision whether to continue taking medications for IBD during pregnancy can be a difficult one. Most of the medications that are used to treat IBD are considered safe in pregnancy. As complications and adverse outcomes in pregnancy are usually associated with active disease, the benefits of keeping IBD in remission usually outweigh the potential risks. However, some medications should not be used in pregnancy. It is therefore very important to review your medications with your IBD team if you are pregnant, or if you are considering pregnancy. Table 1 describes the Category System used by the Food and Drug Administration for drug safety during pregnancy. Details on the most common IBD medications are given below and are summarized in Table 2.

Table 1. US Food and Drug Administration categories for drug safety during

FDA Category Description

Controlled human studies show no risk. Controlled studies in animals and women have shown no risk to the fetus during the first trimester of pregnancy (and there is no evidence of risk in later trimesters).


No evidence of risk in studies. Either animal studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women, OR, animal studies have shown an adverse effect that was not confirmed in controlled studies in women in the first trimester (and there is no evidence of a risk in later trimesters).


Risk cannot be ruled out. Either there are no animal or human studies OR animal studies have shown an adverse effect and there are no well controlled studies in humans AND the benefit from the use of the drug in pregnant women may be acceptable despite its potential risks.


Positive evidence of risk. Positive evidence of human fetal risk, but the potential benefits from the use of the drug in pregnant women may be acceptable despite its potential risks.


Contraindicated in pregnancy. Studies in animals or humans have demonstrated fetal abnormali‐ ties. The risk of the use of the drug in pregnant women clearly outweighs any possible benefit.

Aminosalicylates (5‐ASAs)

5‐ASA medications are generally considered safe to use in pregnancy. All 5‐ASA formulations available in Canada are FDA category B drugs, except Asacol, which is a category C drug. The coating of Asacol contains dibutyl phthalate (DBP). In animal studies, DBP was associated with abnormalities of the kidneys and genital organs when given in doses greater than 80 times the human dose. Your IBD team may therefore recommend switching to a different 5‐ASA medication if you are planning on becoming pregnant.

Sulfasalazine, is safe to use in pregnancy. However, it interferes with folate synthesis so increased supplementation with 2‐5 mg of folate per day is therefore recommended.


Metronidazole (Flagyl®), ciprofloxacin (Cipro®), and amoxicillin‐clavulanic acid (Clavulin®), are some of the antibiotics most frequently used in the treatment of IBD. Metronidazole and amoxicillin‐clavulanate are category B medications and can be used during pregnancy. However, antibiotics use should be limited to short‐term use.

Ciprofloxacin is a category C drug. Although the overall risk is limited, animal studies have shown an increased risk of musculoskeletal abnormalities, so use should be avoided during pregnancy.


Steroids (for example Prednisone®, Budesonide®) are category C medications. Corticosteroid use in the first trimester has been associated with a small increase in the risk of oral clefts (3.35 times more likely). The magnitude of this risk is shown in the adjacent pictogram. As the risk of steroid use is very small, and the potential benefits of treating a significant flare are great, steroids may be recommended to treat IBD flares throughout pregnancy. If steroids are used near the time of delivery, your baby will be monitored to make sure their adrenal glands (which make natural steroid) are working properly. Much less is known regarding the safety of budesonide in pregnancy. Very small case series have not shown any adverse events.


Thiopurines (Azathioprine/Imuran®, 6‐mercaptopurine) are category D medications. This designation is from the 1960s when animal studies using extremely high doses of these medications showed adverse effects. However, multiple studies of IBD patients treated with thiopurines throughout pregnancy have not shown any increased risk of congenital anomalies. Also, the risk of relapse is high when azathioprine is stopped, even in patients who are in remission. For these reasons, 9 out of 10 experts recommend continuing azathioprine throughout pregnancy.22 We do not recommend starting thiopurines for the first time in pregnancy due to the delay in the onset of action, and the risk of pancreatitis, which can be more serious in pregnancy.


Methotrexate is contraindicated during pregnancy—category X. Methotrexate can remain in the body even after it is stopped. It should therefore be stopped 3‐6 months prior to attempting conception.


Infliximab (Remicade®) and adalimumab (Humira®) are category B medications. Both of these medications are antibodies, which are unlikely to cross the placenta in the first trimester, but very efficiently cross the placenta in the late second and third trimesters. Two large safety studies have not shown any increased risk of fetal malformations or neonatal complications with infliximab use in pregnancy compared to the general population. Less data is available for adalimumab. However, small case series show that rates of congenital malformations and ad‐ verse pregnancy outcomes are similar in patients treated with adalimumab compared to IBD patients not receiving adalimumab and the general population.

We therefore recommend, that if possible (you are well, with no symptoms of active disease), infliximab and adalimumab be stopped in the late 2nd or early 3rd trimester. However, if there is evidence of ongoing active disease, it may be safer to continue with anti‐TNF medications as active IBD carries risks of adverse pregnancy outcomes.

These decisions can be difficult to make, and must be discussed in detail with you IBD team. Babies exposed to anti‐TNFs during pregnancy should not receive any live vaccines (common ones are measles, mumps, rubella (MMR), rotavirus, varicella zoster), until at least 6 months of age.

Table 2. IBD Medications and Risks During Pregnancy

Drug Class Example Safety Recommendations
Aminosalicylates Sulfalazine Low risk Increase folate supplementation to 2‐5mg per day
Mesalamine Low risk Class B apart from Asacol® (Class C) ‐can consider switching to different 5‐ASA
Antibiotics Metronidazole Low risk Safe for short term use
Amoxicillin‐ Clavulanic acid Low risk Safe for short term use
Ciprofloxacin Avoid Should be avoided (Class C)—potential in‐ creased risk of joint problems (arthropathy)
Corticosteroids Prednisone®, Budesonide® Low risk Class C—very small increased risk of oral cleft with 1st trimester use. However, use in treating IBD flare has significant benefits.
Thiopurines Azathioprine, 6‐mercaptopurine Low risk Class D based on animal studies and human studies for treatment of cancer. Studies in IBD patients suggest low risk.
Methotrexate Infliximab Contraindicated Stop 3‐6 months prior to conception
Biological agents Methotrexate Low Risk If possible, last dose in late 2nd or early 3rd trimester. No live vaccines to infants until after 6 months of age.
Adalimumab Low Risk Similar to infliximab

What are the recommendations for breastfeeding and IBD?

In 2009‐2010, 87.3% of Canadian women who had a live birth initiated breastfeeding, and 25.9% of women exclusively breastfed for 6 months. Although one large study found that women with IBD were less likely to breastfeed than women in the general population, a recent study from the University of Manitoba showed similar rates in their IBD patients compared to the general population. Breastfeeding has many benefits for both mother and child, and is recommended as the primary form of nutrition for the first six months by Health Canada, the Canadian Paediatric Society, Dieticians of Canada, and the Breastfeeding Committee for Canada. For example, breast milk can help keep your infant healthy by protecting them from illness and it also promotes optimal brain development. In addition, breastfeeding helps to develop and strengthen the bond between mother and child. Breastfeeding may also decrease the risk of developing IBD later in life. Only certain IBD medications are absolutely contraindicated in breastfeeding (see Table 3).

Table 3. IBD Medications and Recommendations for Breastfeeding

Medication Recommendation in Breastfeeding

Compatible. Reports of infant diarrhea.


Metronidazole—not recommended Ciprofloxacin—probably compatible Amoxicillin/clavulanic acid—compatible




Low levels found in breast milk (<1% of maternal dose) and majority excreted in first 4 hours after taking medication. Breast feeding probably safe. Can wait 4 hours between taking medication and breastfeeding to be safe.




Limited human data, probably compatible

What else should I do to prepare for pregnancy?

All women who are considering becoming pregnant should:

  • Avoid alcohol and smoking as they negatively affect infant development.
  • Proper nutrition is a very important part of a healthy pregnancy.
  • Follow Eating Well with Canada’s Food Guide.
  • Take a maternal multivitamin.
  • Limiting caffeine to a maximum of 200 mg per day (about 1 cup of coffee).
  • In addition, for women with IBD, supplementation with 2‐5 mg of folic acid per day both before and during pregnancy is recommended to help prevent neural tube defects.

Your IBD team can provide you with additional nutritional advice for before, during and after pregnancy.


  • Mountifield, R., Bampton, P., Prosser, R., Muller, K., & Andrews, J.M. Fear and Fertility in inflammatory bowel disease: a mismatch of perception and reality affects family planning decisions. Inflamm Bowel Dis 2009;15:720‐725.
  • Olsen, K.O., Joelsson, M., Laurberg, S., & Oresland, T. (1999). Fertility after ileal pouch‐anal anastomosis in women with ulcerative colitis. British Journal of Surgery, 86, 493‐495.
  • Cornish JA, Tan E, Teare J, et al. (2007). The effect of restorative proctocolectomy on sexual function, uri‐ nary function, fertility, pregnancy and delivery: a systematic review. Dis Colon Rectum, 50(8):1128‐38.
  • Riley SA, Lecarpentier J, Mani V, et al. Sulphasalzaine induced seminal abnormalities in ulcerative colitis: results of a sesalazine substitution. Gut 1987;28:1008‐12.
  • French AE, Koren G, Motherisk Team. Effect of methotrexate on male fertility. Can Fam Physician 2003;49:577‐8.
  • Yang H, McElree C, Roth M‐P, et al. Familial empirical risks for inflammatory bowel disease: differences be‐ tween Jews and non‐Jews. Gut 1993;34:517‐524.
  • Bennet RA, Rubin PH, and Present DH. Frequency of inflammatory bowel disease in offspring of couples both presenting with inflammatory bowel disease. Gastroenterology 1991;100(6):1638‐43.
  • Riis L, Vind I, Politi P, et al. A study in a European cohort of patients with inflammatory bowel disease. Am J Gastroenterol 2006;101:1539‐45.
  • Castiglione F, Pignata S, Morace F, et al. Effect of pregnancy on the clinical course of a cohort of women with inflammatory bowel disease. Ital J Gastroenterol 1996;28:199‐204.
  • Habal, F.M., & Huang, V.W. (2012). Review article: a decision‐making algorithm for the management of pregnancy in the inflammatory bowel disease patient. Alimentary Pharmacology and Therapeutics, 35: 501‐515.
  • Norgard B, Hundborg HH, Jacobsen BA, et al. Disease activity in pregnant women with Crohn’s disease and birth outcomes: a regional Danish cohort study. Am J Gastroenterol 2007;102:1947‐54.
  • Cornish J, Tan E, Teare J, et al. A meta‐analysis on the influence of inflammatory bowel disease on pregnan‐ cy. Gut 2007;56:830‐7.
  • Morales M, Berney T, Jenny A, et al. Crohn’s disease as a risk factor for the outcome of pregnancy. Hepato‐ gastroenterology 2000;47:1595‐8.
  • Vermeire S, Carbonnel F, Coulie P, et al. Management of inflammatory bowel disease in pregnancy. Journal of Crohn’s and Colitis 2012;6:811‐823.
  • Iinyckyji A, Blanchard JF, Rawsthorne P, Bernstein CN. Perianal Crohn’s disease and pregnancy: role of the mode of delivery. Am J Gastroenterol 1999;94:3274‐8.
  • Mahadevan U, Sandborn WJ, Li D‐K, et al. Pregnancy outcomes in women with inflammatory bowel dis‐ ease: a large community‐based study from Northern California. Gastroenterology 2007;133:1106‐12.
  • Selinger CP, Leong RWL and Lal S. Pregnancy related issues in inflammatory bowel disease: evidence base and patients’ perspective. World Journal of Gastroenterology 2012;18(21):2600‐2608.
  • Park‐Wyllie L, Mazzotta P, Pastuszak A, et al. Birth defects after maternal exposure to corticosteroids: pro‐ spective cohort study and meta‐analysis of epidemiological studies. Teratology 2000;62:385‐92.
  • Beaulieu DB, Ananthakrishnan AN, Issa M, et al. Budesonide induction and maintenance therapy for Crohn’s disease during pregnancy. Inflamm Bowel Dis 2009;15:25‐8.
  • Cleary BJ, Kallen B. Early pregnancy azathioprine use and pregnancy outcomes. Birth Defects Res A Clin Mol Teratol 2009;85:647‐54.
  • Treton X, Bouhnik , Mary J‐Y, et al. Azathioprine Withdrawal in patients with Crohn’s disease maintained on prolonged remission: A high risk of relapse. Clin Gastro Hepatol 2009;7:80‐85.
  • Peyrin‐Biroulet L, Oussalah A, Roblin X, Sparrow MP. The use of azathioprine in Crohn’s disease during pregnancy and in the post‐operative setting: a world wide survey of experts. Aliment Pharmacol Ther 2011;33:707‐13.
  • Simister NE. Placental transport of immunoglobulin G. Vaccine 2003;104:228‐33.
  • Lichtenstein GR, Feagan BG, Cohen RD, et al. Serious infections and mortality in association with therapies for Crohn’s disease: TREAT registry. Clin Gastroenterol Hepatol 2006;4:621‐30.
  • Katz JA, Antoni C, Keenan GF, et al. Outcome of pregnancy in women receiving infliximab for the treatment of Crohn’s disease and rheumatoid arthritis. Am J Gastroenterol 2004;99:2385‐92.
  • Chambers CD, Johnson DL, Jones KL. Adalimumab and pregnancy outcome: the OTIS autoimmune diseases in pregnancy project. Am J Gastroenterol 2006;101:S421‐S422.
  • Mahadevan U, Cucchiara S, Hyams JS, et al. The London Position Statement of the World Congress of Gas‐ troenterology on Biological therapy for IBD with the European Crohn’s and Colitis Organization: Pregnancy and Pediatrics. Am J Gastroenterol 2011;106:214‐223.
  • Public Health Agency of Canada. Perinatal Health Indicators for Canada 2011. Ottawa, 2012.
  • Kane S, Lemieux N. The role of breastfeeding in postpartum disease activity in women with inflammatory bowel disease. Am J Gastroenterol 2005;100:102‐5.
  • Moffat, D.C., Ilnyckyj, A., & Bernstein, C.N. (2009). A Population‐based study of breastfeeding in inflamma‐ tory bowel disease: initiation, duration, and effect on disease in the postpartum period. The American Journal of Gastroenterology, 104, 2517‐2523.
  • Health Canada. Nutrition for Healthy Term Infants—A joint statement of Health Canada, Canadian Paediat‐ ric Society, Dieticians of Canada and Breastfeeding Committee for Canada. http://www.hc‐‐an/ nutrition/infant‐nourisson/recom/index‐eng.php (Accessed May 10, 2013).
  • Klement E, Cohen RV, Boxman J, et al. Breastfeeding and risk of inflammatory bowel disease: a systematic review and meta‐analysis. Am J Clin Nutr 2004;80:1342‐52.
  • Christensen LA, Dahlerup JF, Nielsen MJ. Azathioprine treatment during lactation. Aliment Pharmacol Ther 2008;28:1209‐13.
  • Saha, S & Wald, A. (2012). Safety and efficacy of immunomodulators and biologics during pregnancy and lactation for the treatment of inflammatory bowel disease. Expert Opin. Drug. Saf. , 11(6):947‐957.

Handout designed by Sharyle Fowler, MD and Megan Sander, MSc RD, University of Saskatchewan. Reviewed by: Natasha Haskey MSc RD and Jennifer Jones, MD, MSc, University of Saskatchewan. Funding for this project provided by the Interprofessional Health Collaborative of Saskatchewan and the Saskatoon Health Region.

Where to find us

9th Floor Victoria Building
Halifax, Nova Scotia
B3H 2Y5

Telephone: 902-473-6456
Fax: 902-473-4406