Women With MS on Fertility Treatment Do Not See Rise in Relapse Risk

Fertility treatment is not associated with an increased risk for relapse among women with multiple sclerosis, including those on DMTs.

Among women with multiple sclerosis MS undergoing fertility treatments, there is no elevated risk for relapse, according to findings from a study published in Neurology.

Women with MS are more likely to be diagnosed with infertility compared with the general population. Despite this fact, women with MS are less likely to undergo fertility treatments, perhaps in part due to published data from small studies that found an elevated risk for relapse following fertility treatment. However, recent, larger studies did not replicate these findings.

As the relationship between fertility treatment and relapse in MS remains unclear, this observational retrospective study was designed to assess risk for relapse following fertility treatments. Patients (N=65) with MS who underwent fertility treatments and were treated at 4 tertiary care centers in the United States were evaluated for relapse in the 3 months after they received their treatments compared with relapses in the 12 months before treatments. Relapse was defined clinically and fertility treatment was stratified into controlled ovarian stimulation (COS), fresh embryo transfer (ET), ovulation induction (OI), and intrauterine insemination (IUI) procedures.

The patients were mean age, 36 (SD, 4.4) at first fertility treatment; 55% had a body mass index (BMI) 18.5-24.9 kg/m2 prior to fertility treatment; 78% were White; 86% had relapsing remitting MS; and 77% were nulliparous.

[C]ontinuing highly effective appropriately timed DMT during FTs may reduce the risk of relapse during this period of marked hormonal fluctuations and stressors.

Overall, 55 patients underwent COS and/or ET and 10 OI with IUI in 110 and 14 procedure cycles, respectively. Among the pooled population, 44% had a live birth or were currently pregnant.

More than half (60%) of fertility treatment cycles occurred within 12 months of disease-modifying treatment (DMT) use, specifically glatiramer acetate (28%), ocrelizumab or rituximab (19%), dimethyl fumarate or diroximel fumarate (7%), fingolimod (4%), and natalizumab (2%). In 43% of fertility treatment cycles, DMT use was continued.

The annualized relapse rate (ARR) in the 3 months post-fertility treatment was 0.19 compared with 0.12 in the 12 months before treatment. Stratified by fertility treatment, the ARR in the 3 months after and 12 months before treatment were 0.63 and 0.16 for COS alone, 0.28 and 0.14 for OI with IUI, 0.13 and 0.11 for COS with ET, and 0 and 0.10 for ET alone, respectively.

New magnetic resonance imaging (MRI) lesions were detected in the 12 months post-fertility treatment among 23% of all cycles and among 37% post-OI with IUI, 25% post-COS alone, 20% post-ET alone, and 19% post-COS with EI cycles.

In only COS procedures, fertility treatment was not associated with an increased likelihood of relapse in the 3 months following compared with 12 months preceding treatment (incidence rate ratio [IRR], 0.95; 95% CI, 0.85-1.76).

Stratified by subgroup, no characteristics were associated with increased risk. However, patients who underwent 2 or more stimulations within 3 months (IRR, 4.00; 95% CI, 0.85-18.80) or received 2000 pg/mL or more estradiol (IRR, 2.40; 95% CI, 0.85-6.81) were trending toward significance.

This study may have been limited by defining relapse by clinical criteria and not by MRI.

Researchers concluded, “This modern multicenter cohort identified no increase in relapse rate after FT [fertility treatments] in a group of women with recent or ongoing (43%) DMT use, regardless of FT type or hormonal protocol used. … [C]ontinuing highly effective appropriately timed DMT during FTs may reduce the risk of relapse during this period of marked hormonal fluctuations and stressors.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Graham EL, Bakkensen JB, Anderson A, et al. Inflammatory activity after diverse fertility treatments. Neurol Neuroimmunol Neuroinflamm. Published March 15, 2023. doi:10.1212/NXI.0000000000200106