Printed on: July 2nd, 2026

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Inflammatory bowel disease: reproductive health and pregnancy

Inflammatory bowel disease: reproductive health and pregnancy

Inflammatory bowel disease (ulcerative colitis and Crohn’s disease) affects over half a million people in the UK (IBD UK Report and Press Release). It commonly presents in the late teens or twenties, so it is important to know about the potential effect of these diseases, and medications used to treat them, on reproduction.

Here, we have summarised CoRSH guidance on sexual and reproductive healthcare for women with inflammatory bowel disease (IBD) (CoSRH Oct 2016), alongside guidance from the 2025 British Society of Gastroenterology IBD Guidelines on the management of IBD in pregnancy.

This article was updated in March 2026.

CoSRH Oct 2016:

• A causal relationship between COCP use and onset or exacerbation of IBD has not been established.
• IBD is UKMEC 1 for Cu-IUD, LNG-IUS and the progestogen-only implant. It is UKMEC 2 for DMPA, POP and CHC (CoSRH 2025 UKMEC).
• Efficacy of oral contraception is unlikely to be affected by large bowel disease, but may be reduced in women with Crohn’s disease involving the small bowel and malabsorption.
• Consider other IBD-associated conditions such as primary sclerosing cholangitis, VTE and osteoporosis.
• Consider interactions with other medications:
  • Ciclosporin levels may be increased by sex steroid hormones. Frequent assessment of renal function and drug-related side-effects may be appropriate.
  • Tacrolimus levels may be increased by ethinylestradiol and some progestogens.
• Condoms: check whether any rectally-administered medications which may spread onto the genital skin could reduce the efficacy of condoms (e.g. oil-based preparations). Patient should check on package insert or with manufacturer).
• Women taking CHC should stop this 4 weeks before major elective surgery.
• Laparoscopic sterilisation: safety and success may be affected by previous pelvic or abdominal surgery. 

You may also find our article Preconception advice helpful here. 

Women

Contraception and medication reviews are an ideal opportunity to discuss future pregnancy plans, and to refer to gastroenterology to consider stopping or switching medications if required. 

• IBD management should be optimised before pregnancy. The British Society for Gastroenterology (BSG) recommends aiming for at least 3 months of steroid-free remission (British Society of Gastroenterology IBD Guidelines).
• Women with Crohn’s disease may have slightly reduced fertility, especially when their disease is active or they have adhesions from surgery (CoSRH Oct 2016).
• Women with ulcerative colitis have the same fertility as those without the disease, unless they have had pelvic surgery, e.g. proctocolectomy, in which case they may have 3 times the risk of infertility (CoSRH Oct 2016).
• Be particularly mindful of mental health concerns before, during and after pregnancy because of the higher rate of mental health problems in people with IBD (British Society of Gastroenterology IBD Guidelines).
• Folic acid: use standard 400mcg dose for most women. High-dose (5mg/d) folic acid may be needed in malabsorption or in those on sulfasalazine (see full details below) (British Society of Gastroenterology IBD Guidelines).
• Methotrexate, JAK inhibitors and S1P modulators must be stopped 3m before conception (British Society of Gastroenterology IBD Guidelines).
• Some medications must be avoided in pregnancy. For others, the gastroenterology team will weigh the risk of harm from relapse against any potential harms from the medication, and will often opt to continue (British Society of Gastroenterology IBD Guidelines). For more details, see section on medications below. 

Men

There is little evidence about the effect of IBD on male fertility. An analysis of three studies of men with Crohn’s disease suggested reduced fertility, but it did not take into account whether participants had chosen not have children. Two studies of men with ulcerative colitis have found no reduction in fertility (CoSRH Oct 2016). 

We should encourage men on immunosuppressants who are planning to conceive to discuss this with their specialists because, occasionally, the advice will be to withhold medications prior to conception. The Best Use of Medicines in Pregnancy website (BUMPS), produced by the UK Teratology Service, gives useful advice, in patient-friendly form, for both women and men planning to conceive. Examples for men include:

• Methotrexate: manufacturers advise that men stop 3m prior to conception as a precaution, but studies looking at pregnancies fathered by around 1000 men on methotrexate haven’t shown any evidence of harm, and some men choose to continue methotrexate during conception after weighing up the risk/benefit with their specialist (BUMPS, accessed March 2026).
• Sulfasalazine: for male patients affected by subfertility, the BSG recommends switching to 5-ASA if possible (British Society of Gastroenterology IBD Guidelines). Evidence is limited, but does not show a link between male sulfasalazine use and birth defects or miscarriage (BUMPS, accessed March 2026).
• Infliximab: “There is currently no evidence that infliximab used by the father can harm the baby through effects on the sperm” (BUMPS, accessed March 2026). 

From BJGP article (BJGP 2014;64:593):

• All patients taking medication or with active disease should be referred to a specialist.
• Flares during pregnancy are associated with preterm labour and foetal loss: refer urgently to a gastroenterologist.
• The benefits of remission are generally considered to outweigh the risks of medication to the foetus (see table).
• Those taking glucocorticoids should be screened for gestational diabetes. 

The BSG adds (British Society of Gastroenterology IBD Guidelines):

• Most women require 400mcg/d of folic acid. Women at risk of malabsorption (e.g. significant small bowel resection or active small bowel disease) and those taking sulfasalazine need 5mg folic acid/d.
• An MDT approach is recommended, with joint obstetric and gastroenterology clinics being highlighted as potentially helpful.
• Uncontrolled IBD is associated with preterm birth and low birth weight.
• Indications for surgery in pregnant women with IBD are the same as for non-pregnant patients.
• Endoscopy should only be done in pregnant women if essential for clinical decision-making.
• Pregnant women with active IBD should be given VTE prophylaxis for the duration for the third trimester.

The following advice has been adapted from the British Society of Gastroenterology IBD Guidelines. We recommend that you check the BNF for specific drug queries.   

For most women, the mode of delivery will be determined by obstetric considerations and patient preference, as for the rest of the pregnant population. Where there is active perianal disease, ileoanal pouch or ileorectal anastomosis, the BSG tells us that caesarean section is ‘often preferred’ (British Society of Gastroenterology IBD Guidelines).

Breastfeeding

See table above, adapted from the BSG guidelines. The BSG summarises this as “medications that are low risk in pregnancy are also low risk in breastfeeding”. Breastfeeding does not affect the course of IBD (British Society of Gastroenterology IBD Guidelines).

Infants exposed to biologics 

Babies whose mothers were on biologics during pregnancy should postpone any live vaccines, including BCG. The Green Book recommends postponing to 6m of age (Green Book, chapter 6, accessed March 2026). However, the BSG goes further, delaying until they are >12m of age (British Society of Gastroenterology IBD Guidelines). 

The Green Book recommends that for breastfed infants of mothers currently using immunosuppressive therapy, we take advice on whether live vaccines are safe (Green Book, chapter 6, accessed March 2026). The BSG guidance has some reassurance that while low levels of biologic therapies can be detected in breastmilk, this is not likely to confer additional risk to the baby, and the decision to vaccinate can be based on utero exposure only (British Society of Gastroenterology IBD Guidelines). 

Disease control

Around one-third of women will experience a flare of IBD symptoms in the 12 months postpartum. 

Risk is higher in women with active disease from conception up to the end of the second trimester, and in those who reduced their maintenance treatments during pregnancy. This highlights the importance of good preconception and pregnancy counselling about the safety of drug treatments and the importance of maintaining good disease control.

Risk of disease flare was not influenced by mode of childbirth, breastfeeding, IBD type or duration of disease (Inflam Bowel Dis 2020;26:1926). 

Inflammatory bowel disease: reproductive health and pregnancy IBD is UKMEC 1 for Cu-IUD, LNG-IUS and the progestogen-only implant. DMPA, POP and CHC are UK MEC 2. Active Crohn’s disease and pelvic surgery may reduce fertility. All women taking medication or with active disease should be referred to a specialist during pregnancy. JAK inhibitors, S1P inhibitors and methotrexate should be stopped 3m prior to preconception, but many other drugs in IBD are low risk. Women using sulfasalazine, or at risk of malabsorption, need high-dose folic acid (5mg/d). Women taking steroids should be screened for gestational diabetes. Most women can have a vaginal delivery.

Consider plans for future pregnancy in women with IBD at contraception or medication reviews.