The information in this brochure is intended as educational and should not replace the advice of your physician or other qualified healthcare provider. Talk to your physician if you are planning to start a family.

MULTIPLE SCLEROSIS AND

DECIDING TO START A FAMILY The questions you have. The answers you need.

TABLE OF CONTENTSTHINKING OF BECOMING PREGNANT 2

YOU HAVE DECIDED TO BECOME PREGNANT 4

WHAT TO EXPECT DURING PREGNANCY 6

WHAT TO EXPECT DURING DELIVERY 8

TAKING CARE OF YOURSELF AFTER BIRTH 10

ADDITIONAL RESOURCES 12

THINKING OF BECOMING PREGNANTDoes MS affect fertility?No, there is no evidence to suggest that male or female fertility is adversely affected by MS. In fact, contraception should be practiced (by either the man or woman) if the couple want to avoid pregnancy.

Why is it important to speak with my physician about my plans to start a family?Your physician will know if the MS medication you are on is safe for use during pregnancy and if there is a time period needed between stopping the medication and trying to become pregnant. Some disease modifying therapies (DMTs) are risky even for men who want to father a child.

How does pregnancy affect MS?Pregnancy does not appear to speed up the course or worsen the effects of MS. Pregnancy has actually been shown to have a protective effect on women with MS. Many studies done in hundreds of women with MS demonstrate that pregnancy reduces the number of MS relapses, especially in the third trimester.

How does MS affect pregnancy?Women with MS may experience greater fatigue than usual and like any other pregnant woman, can have troublesome bowel and bladder problems. Towards the end of the pregnancy, your balance and gait may be affected, again, just like any other pregnant woman. Of course, having MS means that you will want to manage these issues with your healthcare professionals.

MS appears to have little or no effect on pregnancy. There is no evidence that MS is linked to any problems with pregnancy, such as miscarriage, ectopic pregnancy, preterm births, stillbirths, or congenital abnormalities. Women with MS can expect normal pregnancy outcomes.

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Will MS be passed on to my child?MS has no apparent effect on the fetus. MS is not hereditary. Children of women with MS have a 3% to 5% lifetime chance of developing MS. In other words, they have an approximately 96% chance that they won’t develop MS.

What else is important to know when deciding to start a family?Women with MS usually need no special gynecologic care during pregnancy. Labour and delivery are usually the same as in other pregnant women.

However, it is very important to let your physician know that you are thinking about starting a family. As mentioned earlier, your current MS medication may not be safe for your baby and you will need to stop taking them before you try to become pregnant. This is just as important for the men who want to father a child.

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CONNECT WITH A SUPPORT GROUP OR OTHER

MS PARENTS

TALK TO YOUR DOCTOR

PLAN FOR THE FUTURE

YOU HAVE DECIDED TO BECOME PREGNANTIf my current MS medication is stopped, how will my MS be managed?There may be a waiting period between stopping medication and trying to conceive. Your physician will be able to determine how to best manage your MS during this time, and while you are trying to become pregnant. It is ideal to become pregnant as quickly as possible since you will be off medication. Talk to your physician about how you can increase your chances of conceiving quickly.

What if it takes a long time to get pregnant?If your physician suspects a problem with you getting pregnant, there are fertility-increasing options available.

• Ovulation monitoring• Timing intercourse• Hormone level testingRemember, this can be an issue in the general population – it is not strictly related to MS.

Is in vitro fertilization (IVF) an option with MS?If you are having trouble conceiving, IVF can be a consideration for women with MS. However, some studies have shown that certain medications used during the IVF process can increase your risk of experiencing a relapse during the 3 months following IVF treatment. Talk to your physician to determine if IVF is an option for you.

If MS doesn’t affect fertility, why should getting pregnant be a problem?MS can impair sexual feelings or sexual responses.

According to Statistics Canada, almost one in seven Canadian couples trying to have a child seeks medical help to conceive, including using assisted reproductive techniques such as in vitro fertilization.

• Decreased or absent sex drive• Sensations of numbness, pain, or hypersensitivity• Difficulty or inability to get an erection

• Decreased vaginal lubrication• Difficulty or inability to ejaculate

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Additionally, people with MS may experience symptoms of fatigue, spasticity, bladder and bowel disturbances, and lack of orgasm.

All of these factors can have an effect on your intimacy and sexuality. Take steps to manage these sexual problems.

• Step 1: Get comfortable talking about “it”- A discussion of personal sexual problems or preferences between you and your partner

can deepen the intimacy and reduce feelings of anxiety

• Step 2: Talk to your healthcare team- Many sexual problems associated with MS can be medically managed

• Step 3: Identify treatment strategies- Your physician may consult with or refer you to other specialists, including a psychologist,

urologist, and/or gynecologist to help clarify and discuss intimate issues

Confiding in your partner may help to relieve feelings of stress and anxiety that may be interfering with your sexual relationship.

If you are reading any of the available pregnancy books that are not specific to MS, be sure to consult the advice of your healthcare team before following any of the suggested guidelines.

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WHAT TO EXPECT DURING PREGNANCYJust as your physician managed your MS treatment while you were trying to become pregnant, your physician will continue to treat and monitor you throughout your pregnancy.

It is advised to schedule more frequent prenatal visits to monitor your MS and the well-being of your child.

Will the course of my MS be affected by pregnancy?There are many follow-up studies of women with MS going through pregnancy. We now know that during pregnancy there is a significant reduction in relapses, particularly in the third trimester.

During pregnancy there are elevated hormonal levels. One of these hormones, estriol, has been shown to reduce MRI activity in women with MS. Cell production of interferon-gamma, an interferon that worsens MS, is reduced and there appears to be an increase in certain immune cells that may also suppress MS activity in pregnancy.

In studies with long-term follow up of women with MS who had children, no increased disability as a result of pregnancy was found.

Will pregnancy affect my MS symptoms?Unfortunately, there are no well-defined studies of symptoms of MS during pregnancy outside of relapse rate. However, women with MS often report feeling well during pregnancy, but there are no good measures of this.

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It is common among all pregnant women to experience fatigue, bladder, bowel and gait issues. These issues may become more frequent or worsen in women with MS who experienced these prior to becoming pregnant.

All pregnant women need help from time to time. If you aren’t feeling well or are having problems, let your physician know. Don’t be afraid to ask for supportive assistance from your partner, family and friends. Your healthcare team may also recommend appropriate exercises to promote muscular strength and endurance.

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WHAT TO EXPECT DURING DELIVERYLike most first-time expectant moms, you may find it difficult recognizing when you are in labour. Be sure to speak with your healthcare team earlier in your pregnancy to know what to watch for.

Will labour and delivery be normal?Yes, MS does not create any real problems for delivery. Although labour is not affected by MS, the nerves and muscles used for pushing may be affected. This could mean that instrumental assistance may be required or maybe a Caesarean section. Your physician will discuss with you what your delivery options are based on your particular MS symptoms.

Can I use spinal anaesthetics during labour?Yes, it is still possible for you to have local, spinal or general anaesthetics during labour. Epidurals have not been shown to increase the chances of a relapse or impact your level of ability once your baby is born. It is an individual choice as to whether or not to have an epidural.

Is a Caesarean section a safe option?A Caesarean section does not have any impact on the course of MS. There is no evidence that having a Caesarean section will cause a relapse or affect the progression of MS. Having a Caesarean section is an individual choice that you and your physician should discuss.

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TAKING CARE OF YOURSELF AFTER BIRTHWill my MS symptoms change after giving birth? It has been shown that in the first three to six months after delivery, the risk of MS relapse increases. Be on the lookout and report any possible symptoms to your physician. These relapses do not raise your risk of long-term problems.

Can I breastfeed my child?Yes, provided that you are not on an MS therapy. There is no evidence to suggest that breastfeeding is a problem for women with MS or their children. However, MS treatments are not recommended for use while breastfeeding. You should speak with your physician to determine how to manage your MS while you are breastfeeding.

When do I start back on my MS treatment?There is no specific timeline for returning to your MS treatment. How long you decide to breastfeed, is an individual choice. Some mothers choose to resume their MS therapy immediately and feed their baby formula. Only you can decide what the right decision is for you.

How will the postpartum period affect me?The postpartum period begins after the delivery of the baby and ends when the mother’s body has nearly returned to its pre-pregnant state. This period usually lasts six to eight weeks. The postpartum period involves the mother progressing through many changes, both emotionally and physically, while learning how to deal with all the changes and adjustments required with becoming a new mother.

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All new mothers need to take good care of themselves to rebuild strength; plenty of rest, good nutrition, and ask for help.

What else should I know?Plan to focus on your health and on mothering your new little one. Rest as much as you can and leave the housework, laundry, etc. to others. It is generally best for the new mother to be relieved of all responsibilities except the feeding and care of herself and her baby.

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ADDITIONAL RESOURCESMS Society of Canadahttp://mssociety.caToll free to reach the nearest regional office: 1-800-268-7582

MS Discussion Forumhttp://www.msdiscuss.com

National Multiple Sclerosis Societyhttp://nationalmssociety.org

MS Connectionhttps://www.msconnection.org

Mothers Assisting Mothers (US)http://www.ms-mam.org

The Consortium of Multiple Sclerosis Centers (US)http://www.mscare.org

References:

BMJ Group. Fertility treatment linked to increased relapse rate among MS patients. Accessed July 2014 at http://group.bmj.com/group/media/latest-news/fertility-treatment-linked-to-increased-relapse-rate-among-ms-patients.

Confavreux C, Hutchinson M, Hours M, et al. Rate of pregnancy-related relapse in multiple sclerosis. The New England Journal of Medicine. 1998(5):285–291.

Devonshire V, Duquette P, Dwosh E, et al. The immune system and hormones: review and relevance to pregnancy and contraception in women with MS. The International MS Journal. 2003(10):44–50.

Dwosh E, Guimond C, Duquette P, et al. The interaction of MS and pregnancy: a critical review. The International MS Journal. 2003(10):38–42.

Finkelsztejn A, Brooks JBB, Paschoal FM, et al. What can we really tell women with multiple sclerosis regarding pregnancy? A systematic review and meta-analysis of the literature. An International Journal of Obstetrics and Gynaecology. 2011(118):790–797.

Giannini M, Portaccio E, Ghezzi A, et al. Pregnancy and fetal outcomes after glatiramer acetate exposures in patients with multiple sclerosis: a prospective observational multicentric study. Neurology. 2012(12):124–130.

John Hopkins Medicine. Health Library. Multiple Sclerosis and Pregnancy. Accessed March 2014 at http://www.hopkinsmedicine.org/healthlibrary/conditions/physical_medicine_and_rehabilitation/multiple_sclerosis_and_pregnancy_85,P01160/.

Langer-Gould A, Huang S, Gupta R, et al. Exclusive breastfeeding and the risk of postpartum relapses in women with multiple sclerosis. Archives of Neurology. 2009(8):958–963.

Michel L, Foucher Y, Vukusic S, et al. Increased risk of multiple sclerosis relapse after in vitro fertilization. Journal of Neurology, Neurosurgery and Psychiatry. 2012(83):796–802.

MS Australia. Pregnancy and MS: Your Questions Answered. Accessed April 2014 at http://www.msaustralia.org.au/sites/default/files/ms_pregnancy.pdf.

Multiple Sclerosis Association of America. About MS. Frequently Asked Questions about MS. Accessed March 2014 at http://www.mymsaa.org/about-ms/faq/.

Multiple Sclerosis Foundation. Coping with Multiple Sclerosis. MS Medications and Oral Contraceptives: What you need to know. Accessed March 2014 at: http://www.msfocus.org/article-details.aspx?articleID=22.

National Multiple Sclerosis Society. Pregnancy and Reproductive Issues. Accessed March 2014 at http://www.nationalmssociety.org/Living-Well-With-MS/Family-and-Relationships/Pregnancy.

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