Pregnancy Concerns in Patients with Ileal Pouch Anal Anastomosis for Ulcerative Colitis: Time for Increased Education Across Specialties

Abstract

Pregnancy is an emotionally charged and physically demanding time in a woman’s life. Patients who have had surgery for ulcerative colitis during their reproductive years provide a unique set of challenges for physicians before and during pregnancy. Pregnant women who have undergone surgery for medically refractory ulcerative colitis, usually total abdominal colectomy with ileal pouch anal anastomosis (IPAA), often have a close relationship with their surgeon and gastroenterologist. The patient’s surgeon, gastroenterologist or obstetrician may provide counseling regarding pre-pregnancy issues and pregnancy management, with the advantage that these specialists may have diverse understanding of and approaches to the issues based on their differing training environments, respective literatures, and practice settings. In this issue of Digestive Diseases and Sciences, Bradford et al. [1] assess differences in reproductive and pregnancy-related recommendations in this population using a survey design encompassing multiple clinical vignettes detailing multiple management options. They examined the impact of fertility on IPAA, the timing of IPAA in relationship to pregnancy, delivery recommendations, and who should be providing advice, reporting major differences in advice given among the specialties studied. The data in the literature that support counseling decisions range in focus from the effects of IPAA on fertility and the choice of practitioner providing advice to these patients, which are unsupported by data, to controversial surgical timing issues supported by few data. The authors highlight some of the most difficult areas of decision-making in terms of reproduction in women with a J-pouch. The survey data they obtained were derived from responses to an invitation distributed to two national gastroenterology and surgical professional society email lists. The obstetricians surveyed were from two large obstetric groups in Southern California. Very few of the respondents saw more than five pregnant IBD patients per year and likely far fewer of these patients had J-pouches. Since education informs excellent care, in this very specialized area of inflammatory bowel disease, the presence of key data is essential. A limited Pubmed search shows that the bulk of the information published on pregnancy and ulcerative colitis is in the gastrointestinal and surgical literature (Table 1). Obstetricians—who provide J-pouch patients with pre-pregnancy counseling, discuss pregnancy management issues, and make delivery decisions, may have the least readily available patient resource information. Most of the quality measures for IBD care currently in development in the USA are focused on treatment-related issues rather than physician and patient education [2]. Decreased fertility in patients after IPAA should be the least controversial topic addressed in this manuscript since a large body of literature supports this issue. Patients undergoing traditional IPAA procedures have extensive manipulation of the pelvis that likely leads to adhesions and alterations of tubal anatomy which may adversely affect fertility. In a recent meta-analysis, the relative risk of infertility after IPAA was reported to be 3.91 with average infertility rates 20 % before surgery and 63 % after surgery [3]. A complete laparoscopic approach to IPAA reduces infertility after IPAA: in a two center study, 11 out of 15 patients were able to conceive successfully after laparoscopic IPAA [4]. Similarly in a 50 patient cross-sectional study, the spontaneous pregnancy rate in patients with a K. L. Isaacs (&) Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA e-mail: kim_isaacs@med.unc.edu