Dear Professor Winston
I am 34 and my husband is 35 and we are trying to get pregnant. I already have a son whom I fell pregnant with the 2nd month of trying. I fell pregnant with my second baby in Nov 2012 again in the 2nd month of trying. I had a missed miscarriage in Feb 2013 when I thought I was 13 weeks but baby had stopped growing at 6 weeks. We started trying again immediately but by Nov 2013 we hadn’t fallen pregnant and I went in for surgery to have a stoma formed. All the team involved with me knew I wanted another baby and I she been advised the surgery would not affect fertility. We have been trying again since March this year but still no success. I have almost regular cycles between 27 and 29 days and appear to be ovulating according to ovulation urine tests. We are having sex every other day as soon as my period has finished until the day after ovulation, usually an extra day when am ovulating. I have started taking vit b12 and agnus castus as I was worried I may be ovulating too late in my cycle, at times around days 17 or 18. What should my next steps be? D.

Reply…

Dear D,

Thank you for your prompt reply to my query and the answer that your operation for a stoma was done because you had Crohn’s disease – which you must have realised is what I suspected from my brief emailed query to you. I am extremely glad to hear that you are now in good health following the surgery.

I am afraid the news I have for you is not wholly good. Sorry to say this but irrespective of what you may have been told, there is a an association between female infertility and Crohn’s. Male infertility is not that uncommon with this disease, but it is forgotten that this also applies to female infertility, particularly after bowel surgery. I have seen numerous cases during my career and in general, the adhesions after bowel surgery for Crohn’s are much more common than after ulcerative colitis. These adhesions frequently affect the tubes and ovaries, so whilst you may well be ovulating the egg is not being picked up effectively and being transported in the tube. This is most likely to be the problem in your case because before surgery you were very fertile, getting pregnant very easily. I note that you have had a miscarriage and the medical literature is somewhat confused about this – some research papers say there is no increased risk of miscarriage, but others disagree. I have certainly seen this but whether it was due to active inflammatory bowel disease is difficult to establish. The biggest series I know of in the world medical literature is that by Dr Mayberry, published in 1986 in the journal called ‘Gut’. He interviewed 275 patients with Crohn’s and did not find ash increase in miscarriage but 16% of the patients who got pregnant had a premature labour (over twice the normal risk). Also 42% of these women of childbearing age failed to get pregnant whether they had had surgery or not. But there is no doubt that after surgery this is much more likely.

What can you do about it. Well firstly, I guess rejoice in two healthy uncomplicated pregnancies. But if you are really keen to get pregnant again the issue really is whether your tubes are open and whether you have adhesions preventing an egg entering the tube. Laparoscopy can certainly be considered and different surgeons will, have different views about doing this given the risk that this procedure might have to your bowel. It certainly is possible as I have done a number of such interventions using a laparoscope which damage and occasionally it has been possible to divide adhesions successfully. Less invasive and a bit safer would be to have a womb x-ray, hysterosalpingography (HSG), which should ascertain whether the tubes are fully open. In my view an HSG is necessary for another reason because people with Crohns quite frequently have a fistula – a connection – between the bowel and the uterus. It is also true that on uncommon occasions there can be damage to to the wall of the uterus even though the bowel is not stuck to it and an x-ray can identify this. Incidentally, if you do have an HSG, I advise having a short course of antibiotics starting two or three days before the x-ray to reduce the risk of any infection. On rare occasions there can also be changes in the uterus or very infrequently the vagina. This seems very unlikely in your case from what you tell me. Finally, most women with Crohn’s affecting the uterus have changes in their periods, which are often heavier or more irregular.

Firstly, of course, you may still get pregnant (but take longer than usual) without any treatment. As to treatment, if it is necessary, laparoscopic surgery would be generally my first option, or possibly open surgery – but this depends I think on the experience of the doctor treating you. IVF is an alternative and has undoubtedly been effective in women who not have inflammatory involvement of the uterus. But egg collection is a bit more risky because the bowel may be stuck to one or both ovaries.

I think that on the whole you will need to think very carefully about having more investigations, given the risks and the fact you are fortunate and have had two successful pregnancies (and without any flare up of your bowel disease). But this is something you may well want to discuss with your doctor. By the way, sceptic that I am, I do not know of any serious evidence that vitamin B12 or agnus castus will improve your chances – though regular sex undoubtedly will.

My best wishes
Robert Winston

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