Fertility and pregnancy in inflammatory bowel disease.

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Inflammatory bowel disease (IBD) is a chronic disorder affecting young adults in the reproductive years. It is common for both female and male patients with IBD to ask questions about IBD’s effect on their relationships, sexual and reproductive function, in particular fertility, the outcome of pregnancy and its possible effects on the disease. An open discussion of the social situation and education targeted at these issues therefore forms an essential part of the management of any young person with IBD. The questions that are most commonly asked are summarised in Table ​Table1.1. In order to answer these questions we need evidence. There are few large prospective case controlled studies to provide the information which is required but the available data, some of it from small observational studies, will be summarised in this chapter. Table 1 Questions commonly asked by IBD patients SEXUAL HEALTH It is well established that general measures of quality of life are impaired in patients with IBD[1]. Sexual health is an important aspect of quality of life which is often overlooked in a routine gastroenterological consultation. Sexual problems in IBD often seem to be focused around three major factors: body image problems, difficulties with social relationships and impaired sexual function[2]. Crohn’s disease (CD), in particular has been shown to have an impact on self-image, social relationships and sexual function[1]. Body image concerns are frequently found in IBD patients relating either to the direct physical effects of their disease such as weight loss, growth retardation as a result of chronically active disease in childhood, fistulae or perianal disease. The effect of surgery especially when a stoma is involved is associated with low self-esteem and poor body image. The side effects of steroids and other medications may lead to weight gain, hirsutism, skin changes and other features which promote feelings of unattractiveness. There is some evidence that psycho-social effects of stoma surgery performed in childhood, before puberty may be less severe than if such surgery is performed during the teenage and early adult years[3]. Partners of IBD patients with stomas have been found to be more likely to be able to accept the stoma than the patient themselves[4]. Psychological fears of loss of control of bodily functions and the fear of rejection by new or established partners in an intimate relationship all contribute to difficulties in social and sexual relationships. Counselling and practical advice and support is frequently helpful, but the need for it is not always identified in general gastroenterological practice. Some studies have reported an increase in sexual difficulties including dyspareunia in women who have had surgery for IBD and there is some evidence that patients with IBD may delay or even defer pregnancy because of their disease[4,5]. Most of the reports of sexual dysfunction are in women with Crohn’s disease. There are no specific reports of sexual dysfunction in women with ulcerative colitis (UC) who have not had previous surgery. In men with IBD the risk of impotence after proctocolectomy is the main concern[4]. Advances in surgical technique have decreased although not eliminated post-operative sexual dysfunction, and this seems to apply to both conventional proctocolectomy and pouch surgery with a reported incidence of impotence of around 4%-8%[6]. It is important to remember that patients are often quite reluctant to discuss such delicate matters and tactful prompting and adequate time during the consultation is the key to their detection.