In IBD, male infertility is thought to be more common than in the general population. It is not clear whether this is due to the disease itself or a reduced desire to have children associated with reduced self-confidence, self-image, abdominal pain, fear of hereditability, etc.

2. What are the possible explanations for male infertility in IBD?

Reduced sperm production due to the effects of drugs used to treat IBD.

Sulphasalazine: used mainly to treat colitis for over 60 years, it can cause a reduced sperm count and sperm abnormalities in over 80% of men. This effect is reversible once Sulphasalazine is withdrawn, usually within 3 months.

3. Does Sulphasalazine cause birth complications?

No – there is no increase in birth defects, still births, miscarriages or pre-term deliveries compared to the general population.

4. What effect does Methotrexate have on males who wish to conceive?  (this drug is discontinued in women who wish to conceive due to associations with birth defects).

First of all it can cause a reduced sperm count, but this is reversible once the drug is withdrawn. However it is generally not thought to be associated with adverse pregnancy outcomes in men exposed to Methotrexate before conception. Some would therefore say that there is no reason to defer family planning whilst the male partner is on this drug. However most would recommend caution and to stop the drug at least 4 months prior to conception.

5. Does Azathioprine or 6-Mercaptopurine have any effect on male fertility?

It is not known for certain whether exposure to these drugs in men leads to decreased fertility or adverse pregnancy outcomes, due to sparsity of data. However it has been accepted for two decades that women who are exposed to these drugs have no reduced fertility or abnormal pregnancy outcomes.  Similarly these treatments do not appear to affect male fertility or pregnancy complications. If discontinuing the drug is likely to lead to a relapse in the IBD condition, this may be more detrimental to the pregnancy outcome than the effect of the drug itself. Therefore most gastroenterologists would not withhold treatment in males who are planning to have children.

6. What can steroids do to male fertility and pregnancy outcomes?

This doesn’t seem to be linked to infertility, although steroids may decrease sperm concentration and sperm motility.

7. Is Infliximab safe if a male wants to conceive?

The biologics may be associated with reduced sperm motility which may impact on fertility. However most studies in IBD or other conditions which benefit from Infliximab, do not seem to report problems associated with conception or fathering a healthy child. It is not known if the fetus may be affected by antibodies in the semen, therefore barrier methods of contraception could be considered during the pregnancy.

8. Which antibiotics may be problematic in males with IBD?

There are limited studies, but the use of Metronidazole or Ciprofloxacin (mainly for fistulising Crohns disease) may be factors contributing to male infertility.

9. What can be done to help patients with male infertility?

In general it is recommended to control their IBD and optimise nutritional status. Cessation of any drugs that may be associated with altered sperm quality may help. But this needs to be weighed against the health benefits derived from the medication.

Sulphasalazine: advise a switch to Mesalazine at least 4 months prior to attempting conception.

Steroids: short courses to control active disease are beneficial.

Azathioprine/ 6-Mercaptopurine: no strong evidence exists to recommend stopping these drugs prior to conception.

Infliximab/ Adalimumab: no evidence that stopping these drugs will improve fertility

10. Can surgery hinder chances of conceiving?

Males who undergo ileoanal pouch surgery for ulcerative colitis (UC) may experience retrograde ejaculation and erectile dysfunction. However, overall no change or even an improvement in sexual function occurs after surgery.

There should not be any impact of other forms of surgery on fertility.

11.   Summary

On balance, there are very few concerns about male infertility in IBD. As long as the patient is otherwise in good health, is a non-smoker and exercises with a healthy diet, a patient in remission from his Crohn’s or colitis should have no greater concerns than the non-IBD male about the ability to conceive and father a child. There may be drugs that are associated with reversible sperm problems such as Sulphasalazine and Methotrexate, but risks of harm to the fetus with any medication used in IBD is very low.

12.   Concerns

If you have any specific concerns, this should be raised with your GP, IBD nurse or gastroenterologist. The information provided here is an overview based on clinical guidelines and current practice, but practice may vary due to individual circumstances.

USEFUL LINKS:

Chana supports couples in the Jewish community who may feel isolated and need medical information and support to help them deal with the challenge of infertility.  www.chana.org.uk