Hormonal changes affect MS activity – ECTRIMS 2017
Highlights from the 7th Joint ECTRIMS-ACTRIMS MEETING, OCTOBER 25-28, Paris, France
It’s been well established that women with multiple sclerosis have fewer relapses during pregnancy, but at risk of relapses in the 3-6 months after childbirth (Vukusic and colleagues. Brain 2004;127[Pt 6]:1353-1360). A developing fetus is “foreign” tissue, from an immune point-of-view, so the immune response shifts to a less reactive profile during pregnancy, enabling the fetus to grow and develop. This less reactive profile translates to fewer MS relapses during pregnancy, but there can be a rebound effect as the woman’s immune system returns to normal after the baby is born.
An Italian study has looked at what happens if there is a miscarriage (Landi and colleagues. ECTRIMS 2017; abstract P326). The researchers used data from 88 miscarriages in 69 women over a 33-year period. The rate of relapses was unchanged before and after a miscarriage. However, there were more flare-ups in the brain, as shown by inflammatory lesions visible on MRI, after miscarriage, indicating that there was a reactivation of MS after a miscarriage/ This would appear to be because after a miscarriage, the body was returning to its usual immune profile, and had lost the protection provided by pregnancy.
A curiosity of the ECTRIMS meeting was that the printed abstract of the above research differed from what was presented. What was shown was a report on the effects of abortion on MS. The study looked at 139 spontaneous or elective abortions in 114 women for the period 1995-2017. The relapse rate tended to go up after abortion, and there was a significant increase in inflammatory activity seen on MRI. When there was a relapse, it occurred about 63 days after the abortion. The relapse risk was higher if the duration of pregnancy was shorter, which can be interpreted in two ways: with a shorter pregnancy, there was less time for the immune system to shift to a less inflammatory profile; and greater inflammatory disease activity at the start of pregnancy may have contributed to a spontaneous abortion (most abortions in this series were spontaneous rather than medically induced). Both of these studies suggest that after a miscarriage or abortion, it may be advisable to re-start an MS medication as soon as possible to prevent an inflammatory flare-up.
MS is generally not believed to have a significant impact on a woman’s fertility, although women with MS are less likely to undergo treatment for infertility (Houtchens and colleagues. ECTRIMS 2017; abstract P356). Infertility treatments, such as in vitro fertilization (IVF), include hormonal therapies, which can affect MS disease activity. A study five years ago found that women with MS undergoing assisted reproduction had 7-fold risk of a relapse if treatment didn’t result in a pregnancy (Correale and colleagues. Ann Neurol 2012;72:682-694). The same researchers have revisited this issue using pooled results from several centres (Bove and colleagues. ECTRIMS 2017; abstract P352). They again found that relapse rates are higher in the three months after infertility treatment, and there was a trend to a higher relapse risk for up to a year after the procedure. Some infertility drugs are more likely to be associated with relapses, so this needs to be discussed with the gynecologist before undergoing infertility treatment.
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